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I LIBRARY OF CONGRESS. 

M 9—165 



A TREATISE 



THE DISEASES 



mFANCY A^^D CHILDHOOD 



BY 



J. LEWIS SMITH. M.D. 



CLINICAL PROFESSOR OF DISEASES OF CHILDREN, BELLEVUE HOSPITAL MEDICAL COLLEGE: PHYSI- 
CIAN TO CHARITY HOSPITAL; PHYSICIAN TO THE N. Y. FOUNDLING ASYLUM; PHYSICIAN TO THE 
N. Y. INFANT ASYLUM; CONSULTING PHYSICIAN TO THE DEPARTMENT OF CHILDREN'S DIS- 
EASES, BUREAU FOR THE RELIEF OF THE OUT-DOOR POOR, BELLEVUE; CONSULTING 
PHYSICIAN TO THE NURSERY AND CHILD'S HOSPITAL, COUNTRY BRANCH; CON- 
SULTING PHYSICIAN TO THE INFANT'S HOSPITAL, RANDALL'S ISLAND. 



SEVENTH EDITION, THOROUGHLY REVISED. 



WITH FIFTY-ONE ILLUSTRATIONS. 





i^ 



PHILADELPHIA: 

LEA BROTHEES & CO. 

1890. 






Entered according to Act of Congress, in the year 1890, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress at Washington. All rights reserved. 



Westcott & Thomson, William J. Dornan, 

Slereotypers and Electrotypers, Philada. Printer, Philada. 



PREFACE. 



Since the issue of. the Sixth Edition of this treatise in 1886 so many ad- 
ditional facts have come to light relating to the etiology, nature, and treat- 
ment of the diseases of children that the necessary revision has produced 
virtually a new book. In the amount of information presented, the work 
may properly be considered to have doubled in size, but this real growth 
has been accommodated without rendering the volume inconveniently large. 
The author has been careful in rewriting to exclude all obsolete material, 
and to condense the text to the limits of clearness. Among the diseases 
treated of in this and not in the former editions we may mention Conjunc- 
tivitis, Icterus, Sepsis, Umbilical Diseases, Hasmatemesis, Melaena, Sclerema, 
(Edema, and Pemphigus of the new-born ; Epilepsy, Tetany, Appendicitis, 
Typhlitis, and Perityphlitis. The paper on Intubation, by Dr. Joseph 
O'Dwyer, will be found interesting and instructive to those who perform 
this operation, as well as to those who wish to learn how to do it. 

In order to make the book in the highest degree useful to the practitioner 
prevalent and fatal diseases have been described at considerable length, and 
special attention has been bestowed upon the treatment. Modes of treatment 
employed by physicians of world-wide reputation are in many instances 
related, and cases are detailed showing the effects of remedies. Recent 
investigations and discoveries relating to the bacterial origin of the local as 
well as constitutional diseases of early life have necessitated many changes 
in the text, and it is believed that all the important facts relating to the dis- 
eases treated of, brought to light by recent researches, are set forth in the 

proper chapters. 

J. L. S. 
New York, September, 1890. 



LIST OF ILLUSTEATIONS. 



fict. page 

1. Congenital Deformity 38 

2. Milk-Globules 48 

3. Colostrum-Corpuscles 48 

4. Protuberant Abdomen in Rachitis 93 

5. Acrania 97 

6. Meningocele 99 

7. Spina Bifida 101 

8. Epithelium covered by Spores of. OTdium Albicans 147 

9. Spores and Branches of the Oi'dium Albicans 147 

10. Skeleton of Congenital Rachitis 181 

11. Head of the Rachitic Child 192 

12. Rachitic Spinal Curvature 193 

13. Rachitic Deformities 194 

14. Rachitic Deformity of Chest 195 

16. }> Pelvic Deformities 196 

17. j 

18.1 

^Rachitic Deformity of Femur 196 

20.] 

V Deformities of Femur, Tibia, Fibula 197 

22. Scrofulous Dactylitis 209 

23. Case of Strumous Inflammation of tlie Joints 216 

24. Bronchial Phthisis 229 

25. Bacillus Tuberculosis . . . , 239 

26. Syphilitic Dactylitis 258 

27. Syphilitic Teeth 259 

28. Partial Collapse of Lung from Pertussis 438 

29. Bacillus Typhosus 457 

30. Cerebro-Spinal Fever 483 

31. Rheumatic Subcutaneous Nodules 508 

32. Section of Rheumatic Nodule Magnified 508 

33. Chronic Rheumatism 509 



VI LIST OF ILLUSTRATIONS. 

FIG. PAGE 

34. Congenital Hydrocephalus 543 

35. Congenital Hydrocephalus 545 

36. Acquired Hydrocephalus 550 

37. Tetany 559 

38. Tetany 602 

39. Facial Paralysis 630 

40. Pseudo-Hypertrophic Paralysis 632 

41. Intubation Instruments 669 

42. Catarrhal or Lobular Pneumonia 692 

43. Catarrhal or Lobular Pneumonia of a More Severe Grade 693 

44. Croupous Pneumonia 695 

45. Septic or Erabolismal Pneumonia 696 

46. Gangrene of the Mouth 746 

47. Intussusception 841 

48.1 

49. I 

* [ Acarus Scabiei 890 

50. 

51. 



CONTENTS. 



PAET I. 

CHAPTER I. 

PAGE 

Infancy and Childhood 33 

CHAPTER H. 
Care of the Mother in Pregnancy 35 

CHAPTER III. 

Mortality of Early Life: Its Causes and Prevention 39 

CHAPTER IV. 

Weight, Growth, Lactation 43 

Wet-Nursing : its Advantages and Hindrances ; Physical Conditions rendering it 
Improper — Colostrum — Human Milk — Modification of Milk in Consequence 
of the Diet — Modification of Milk from its Retention in the Breast — Modifica- 
tion of Milk by Age and by Mental Impressions — Modification of Milk by the 
Catamenial Fimction, Pregnancy, and Other Causes — Effect of Medicines on 
the Mother's Milk — Differences in Women as regards Quantity and Quality of 
Milk — Rules in regard to Suckling — Scantiness of Milk : its Causes and Treat- 
ment. 

CHAPTER V. 
Selection of a Wet-Xl-rse .59 

CHAPTER VI. 
Course of Wet-Xursing — Weaning 62 

CHAPTER VII. 
Quantity of Food Required in Infancy and Childhood 64 

CHAPTER VIIT. 
Artificial FEEDiN(i . . . . 72 

vii 



viu CONTENTS. 



CHAPTER IX. 

PAGE 

Bathing, Clothing, Sleep, Exercise 80 



CHAPTEE X. 

Diagnosis of Infantile Diseases 85 

General Observations — Features, External Appearance of the Head, Trunk, and 
Limbs in Disease — Attitude — Movements — The Voice — Eespiratory System — 
Circulatory System — Animal Heat — Digestive System — Nervous System. 



CHAPTER XI. 
Therapeutics -. ... 95 



PART II. 

DISEASES OF THE NEW-BORN. 

CHAPTER I. 

Malformations 97 

Acrania — Incomplete Brain — Meningocele, Encephalocele, Hydrencephalocele 
— Spina Bifida — Congenital Abnormalities in the Circulatory System — Mal- 
formations of the Heart — Cyanosis — Caput Succedaneum — Cephalhematoma. 

CHAPTER II. 

Diseases of the Neav-born 118 

Inflammation of the Sterno-Cleido-Mastoid Muscle — Mammary Glands — Mas- 
titis — Conjunctivitis — Umbilical Vegetations — Umbilical Hemorrhage. 

CHAPTER III. 

Diseases of the New-born {Continued) 132 

Icterus Neonatorum — Sepsis of the New-born^Thrush. 

CHAPTER IV. 

H^MATEMESIS AND MeL^NA NEONATORUM 150 

Diarrhoea of the New-born — Constipation of the New-born. 

CHAPTER V. 

Tetanus Neonatorum 159 

Sclerema Neonatorum — (Edema Neonatorum — Pemphigus Neonatorum. 



CONTESTS. IX 

PAET III. 
COXSTITUTIOJSTAL DISEASES. 

SECTION I. 

DIATHETIC DISEASES. 

CHAPTER I. 

PAGE 

Eachitis 179 

CHAPTEE II. 
Scrofula 205 

CHAPTEE HI. 
Tuberculosis . . 221 

CHAPTEE IV. 
Syphilis 251 

SECTION II. 

EEUPTIYE FEVEES. 

CHAPTEE I. 

Measles 263 

CHAPTER II. 
Scarlet Fever 271 

CHAPTEE III. 

EOTHELN 328 

CHAPTEE IV. 
Variola— Varioloid 336 

CHAPTEE V. 
Vaccinia 345 

CHAPTEE VI. 
Varicella 353 



X CONTENTS. 



CHAPTER VII. 

PAGK 

Diphtheria 355 



CHAPTER VIII. 
Pertussis 43I 

CHAPTER IX. 
Mumps 445 

SECTION III. 

OTHER GENERAL DISEASES. 

CHAPTER I. 

Intermittent Fever 449 

CHAPTER II. 

Remittent Fever 454 

CHAPTER III. 
Typhoid Fever ■. • • • 456 

CHAPTER IV. 
Cerebro-Spinal Fever 470 

CHAPTER V. 
Acute Rheumatism 503 

CHAPTER VI. 
Erysipelas » 512 



PAET lY. 

SECTION I. 

DISEASES OF THE CEREBRO-SPINAL SYSTEM. 

CHAPTER I. 

Microceph ALUS— Atrophy of Brain .522 



CONTENTS. XI 



CHAPTER II. 

PAGK 

Hypertrophy of Brain 523 



CHAPTER III. 

Thrombosis in the Cranial Sinuses (Phlebitis) 527 

CHAPTER ly. 
Congestion of the Brain 531 



CHAPTER V. 

Intracranial Hemorrhage (Meningeal Hemorrhage, Cerebral Hem- 
orrhage) 534 



CHAPTER VI. 

Congenital Hydrocephalus 542 

CHAPTER VII. 
Acquired Hydrocephalus 548 

CHAPTER VIII. 
Meningitis (Tubercular and Xon-Tubercular) 551 

CHAPTER IX. 
Spurious Hydrocephalus 566 

CHAPTER X. 
Eclampsia 570 

CHAPTER XI. 
Epilepsy 578 

CHAPTER XII. 
Internal Convulsions (Spasm of the Glottis; Laryngismus Stridulus) 590 

CHAPTER XIII. 
Tetany 597 

CHAPTER XIV. 
Chorea 608 



xii CONTENTS. 



CHAPTEK XV. 

PAGE 

Paralysis 621 



CHAPTER XV r. 
Poliomyelitis Acuta Anterior 624 

CHAPTER XVII. 
Facial Paralysis 630 

CHAPTER XVIII. 
Pseudo-Hypertrophic Paralysis 631 

CHAPTER XIX. 
Diseases of the Spinal Cord and its Coverings 634 

CHAPTER XX. 

Congestion of the Spinal Cord and its Meimbrane 635 

CHAPTER XXI. 
Vertebral Caries 637 



SECTION II. 

DISEASES OF THE RESPIRATORY SYSTE:\r. 

CHAPTER I. 

CORYZA 641 

CHAPTER II. 

Laryngitis 644 

Catarrhal Laryngitis — Spasmodic Laryngitis. 

CHAPTER III. 
Membranous Croup (Diphtheritic Croup; True Croup) ........ 650 

CHAPTER IV. 

Intubation 667 

Tracheotomy. 

CHAPTER V. 
Bronchitis 677 



CONTENTS. xiii 



CHAPTEK VI. 

PAGE 

Atelectasis 687 

CHAPTER VIL 

Pneumonia 690 

Catarrhal Pneumonia — Croupous Pneumonia — Septic or Embolismal Pneumonia 
— Cheesy Pneumonia. 

CHAPTER VIII. 
Pleurisy 704 

CHAPTER IX. 
Nervous Cough 737 



SECTION III. 

DISEASES OF THE DIGESTIVE APPARATUS. 

CHAPTER I. 

Simple Stomatitis, Ulcerous Stomatitis, Follicular Stomatitis .... 739 
Simple or Catarrhal Stomatitis — Ulcerous Stomatitis — Aphthous Stomatitis. 

CHAPTER II. 
Gangrene of the Mouth . 744 

CHAPTER III. 
Dentition 750 

Second Dentition. 

CHAPTER IV. 
Catarrhal Pharyngitis, Peripharyngeal Abscess, CEsophagitis .... 756 

CHAPTER V. 

Indigestion, Congestion of Stomach, Gastritis, Follicular Gastritis, 

Diphtheritic Gastritis, Gastro-Malacia 765' 

CHAPTER VI. 
Gastro-Intestinal Bacteria 779 

CHAPTER VII. 
Simple Diarrhcea 781 

CHAPTER VIII. 

Intestinal Catarrh of Infancy (Entero-Colitis) 785 

Cholera Infantum, or Choleriform Diarrhoea. 



XIV CONTENTS. 



CHAPTEE IX. 

PAGE 

Enteritis and Colitis in Childhood 808 



CHAPTER X. 
Constipation . 811 

CHAPTER XI. 
Intestinal Worms 822 

CHAPTER XII. 
Intussusception 837 

CHAPTER XIII. 
Appendicitis, Typhlitis, Perityphlitis 856 

SECTION IV. 
DISEASES OF THE GENITO-URINARY ORGANS. 

Uric-Acid Infarctions — Enuresis— Calculi; Dysuria; Cryptorchia — Vulvitis. . . 866 

SECTION V. 
SKIN DISEASES. 

CHAPTER I. 

Erythematous Diseases 877 

Erythema — Roseola — Urticaria. 

CHAPTER II. 

Papular Diseases • ■ ^82 

Strophulus. 

CHAPTER III. 

Eczema 883 

Scabies. 



THE 



DISEASES OF CHILDREN. 



PART I. 



CHAPTER!. 
INFANCY AND CHILDHOOD. 

Infancy and childhood are, in certain respects, the most important and 
interesting periods of life. To the physiologist they are especially interest- 
ing, because they are the periods of development and of greatest functional 
activity ; to the pathologist, because in them many diseases occur which are 
rarely or never observed in the other periods, or which present in these periods 
peculiar features ; to the physician and vital statistician, because in them 
there are the greatest amount of sickness and largest number of deaths. 

Infancy extends from birth to the age of two and a half years, or 
till the completion of first dentition. In infancy the organs are delicately 
organized, containing a large proportion of water, and hence are easily 
injured. In this period the brain is rapidly developed — more so than any 
other organ ; animal matter predominates in the bones ; the arteries are rel- 
atively large, the muscles small ; the superficial veins are small. Fat is 
absent from the interior of the body, but abundant, in well-nourished infants, 
underneath the integument. The skin is delicate, and its temperature not 
much below that of the blood. At birth it has a reddish hue and is covered 
with soft, fine hairs (lanugo). The reddish hue gradually fades into the 
healthy tint of infancy, and the hairs fall out. In the first two months the 
sweat-glands have little functional activity, sensible perspiration being quite 
rare. Subsequently, perspiration is freer, and in certain diseased states 
{rachitis, etc.) is abundant. The sebaceous glands in the first half of infancy 
are active, particularly upon the scalp, producing often a pale-yellow incrusta- 
tion consisting of sebaceous matter and epidermic cells. 

The secretions from the mucous surfaces commence at an early period. 
At birth the surface of the digestive tube is covered with more or less 
mucus, often in considerable quantity. The meconium is not considered, 
as formerly, to be a product of intestinal secretion. It consists of flat 
epithelial cells, fine hairs, oil-globules, crystals of cholesterin, and brownish 
-or yellowish masses of coloring matter, probably from the liver. It is sup- 
3 33 



34 INFANCY AND CHILDHOOD. 

posed that, with the exception of the coloring matter, the meconium is 
derived mainly from the amniotic fluid which the foetus has swallowed. 

The most wonderful change occurring in the system at birth, through 
the exigencies of the new life, is that in the circulation. The flow of blood 
being interrupted, thrombi form in the umbilical vein and arteries and in 
the ductus arteriosus and ductus venosus, and these vessels gradually atrophy, 
becoming finally shrivelled but permanent cords. I have many times at 
autopsies removed the plug from the ductus arteriosus when death had 
occurred as late as the third week. The foramen ovale closes slowly. I 
have ordinarily found it open till near the end of the first half year, but 
the valve covers fully the aperture, so that there is no detriment to the 
circulation. Both the pulse and respiration are more frequent during 
infancy than childhood, and are more accelerated by moral and physical 
causes. 

The stomach has a smaller relative size and emesis is more readily caused 
than in the adult. The liver is large, occupying at birth nearly half of the 
abdominal cavity, but it grows smaller in successive months. The appetite 
is good and digestion active, so that hunger, when appeased, soon returns. 
The thymus gland, at birth about the size of an unexpanded lung, slowly 
atrophies, but it does not totally disappear till after infancy. 

The kidneys, distinctly lobulated at birth, gradually change their form, 
so as to present in the last part of infancy nearly the shape of the organ in 
the adult. The renal secretion commences early, even before birth. The 
kidneys seldom undergo degenerative changes as in the adult, but they are 
liable to congestions and inflammations. During the first month, and espe- 
cially the first fortnight, crystals of uric acid and the urates are often found 
in the urine in a state of apparent health, causing more or less fretfulness in 
their elimination, staining the diaper, and not infrequently being arrested in 
the tubules of the pyramids, where they can be seen as pink-colored spots or 
lines (uric-acid infarction). These deposits of uric acid and the urates may 
even occur in the foetus, producing obstruction and inflammation of the renal 
tubes. Congenital cystic degeneration of the kidneys is, in the opinion of 
Yirchow, due to them. In early infancy the senses are imperfectly devel- 
oped, the eyes being attracted only by bright objects and the sense of hear- 
ing aff"ected only by loud noises. Sleep is the normal state in the first weeks 
of life : as the age of the infant increases, less and less sleep is required ; 
but the oldest infants need more than children and several hours more than 
adults. 

The new-born infant is apparently destitute of mental faculties. It seeks 
the breast by instinct, and it exhibits no perception or reflection. The loud 
cries with which it commences its existence are not from anger or suffering ; 
they appear to be normal, like the act of nursing, and providentially designed 
in order to expand the lungs. It is not till the close or near the close of the 
first month that the gray substance of the brain begins to appear — the prob- 
able seat of the mind and the source of all mental phenomena. Perception 
and curiosity are early manifested. The infant, as Edmund Burke has 
remarked, is constantly seeking new objects for its amusement, rejecting old 
playthings for such as possess more novelty. Reflection, a higher faculty 
of the mind, appears at a later period. The mind and the bodily organs in 
infancy are, in a high degree, impressionable. Anger is excited by trivial 
causes, but is easily appeased, and the various functions in the system are 
disturbed by agencies which in youth or manhood would have no appreciable 
effect. 

Childhood extends from infancy to the age of fifteen years or puberty. 
It is a period of great physical activity and of rapid growth. The functions 



THE MOTHER IN PREGNANCY. 35 

of the various organs are performed with more moderation than in infancy, 
and are less frequently deranged. The volume of the brain continues to 
increase rapidly, and it becomes firmer than in infancy. It is estimated that 
by the seventh year the weight of this organ has doubled. The mind now 
exerts a controlling influence over the actions of the individual. The 
digestive organs have changed, so that solid food is required. Most of the 
glandular organs are less active than in the greater part of infancy, and 
some of them, as the liver, are relatively smaller. The pulse and respiration 
gradually become less frequent as the child advances in age. 



CHAPTER II. 

CAKE OF THE MOTHEK IN PREGNANCY. 

The frequency of miscarriages and stillbirths, and the large number of 
ill-formed and puny infants born to a precarious and short existence, render 
imperative, on the part of the mother, a strict observance of the laws of 
health, and an avoidance of all exciting or perturbating influences during 
the time when the foetus is being developed. The diet should be plain and 
easily digested, but nutritious. There is often a craving in pregnancy for 
unusual articles of food. These may sometimes be allowed within certain 
limits, provided that they are such as do not derange the stomach. Meats 
and animal broths, together with vegetables and farinaceous food, should con- 
stitute the ordinary diet and should be taken at regular intervals. 

Daily exercise, never violent, but moderate and gentle, is requisite. No 
exercise is better, none safer, and more likely to contribute to cheerfulness 
and healthy functional activity of the organs, than the ordinary household 
duties. Lifting heavy weights or work which, like washing and ironing, 
causes great and continued action of the abdominal muscles, should be 
avoided. Such exercise is highly injurious, and it may produce premature 
labor. Exercise in the open air on foot or by an easy conveyance conduces 
to the health of the mother and the growth and development of the foetus. 
On the other hand, rapid riding over rough roads is one of the most dangerous 
modes of exercise. It has been known to destroy the foetus, which up to 
that time had been apparently vigorous. When such a result occurs there 
is probably more or less detachment of the placenta. 

It being a matter of the utmost importance that the health of the mother 
should continue good during gestation, any disease which she may have in 
this period, and which aff'ects her nutrition or the character of her blood, 
should be promptly cured if practicable, and with the least possible reduc- 
tion of the vital powers. Intermittent fever, occurring during gestation, 
should never be allowed to continue. It seriously retards foetal develop- 
ment and may produce miscarriage. Unless it be controlled by proper meas- 
ures, the off'spring, though born at term, is puny and emaciated. Syphilis in 
the pregnant woman also requires treatment. This disease, readily trans- 
mitted from the mother to the foetus through the ovum or the uterine circu- 
lation, may be eradicated by antisyphilitic treatment of the mother, or at 
least so modified that the infant is born vigorous and healthy. 

The pregnant woman should avoid all causes of undue mental excite- 
ment. This is almost as necessary as the avoidance of great physical exer- 
tion. There is, during pregnancy, unusual susceptibility to mental impres- 



36 CARE OF THE MOTHER IK PREGNANCY. 

sions, and this should be borne in mind not only by the woman herself, 
but by those who associate with her. 

Strong emotions, whether of joy, sorrow,^ or anger, aifect primarily the 
nervous system, but indirectly most of the organs of the body. Observa- 
tions have long established the fact that such emotions influence the state 
and functions not only of the digestive and glandular, but also of the mus- 
cular, organs, as the heart and uterus. Physicians are familiar with cases 
in which vivid mental impressions produced uterine contractions, and even 
miscarriage, or have disturbed the catamenial function. Therefore, the 
associations and cares of pregnant women should be such as conduce to 
cheerfulness and equanimity. 

It is the popular belief and the belief of many physicians that vivid 
mental impressions sometimes have a direct eifect on the development of 
the foetus. Many cases are on record in which infants were born with marks 
or deformities corresponding in character with objects which had been seen and 
had made a strong impression on the maternal mind at some period of gestation. 
Whether the mind of the mother exerts a controlling influence on the form 
and color of the foetus is a subject of great interest to the psychologist as 
well as the physiologist and physician, since it involves no less a question 
than the power and scope of the human mind. Violent emotions, it is admit- 
ted, may aff"ect directly most of the important organs in the system. They 
may derange the liver, causing jaundice, accelerate, or for a moment suspend, 
the heart's action, stimulate the kidneys, causing diuresis, or even the intesti- 
nal follicles, causing watery evacuations. But with all these organs the brain 
is connected by nerves which anatomy reveals. On the other hand, the mother 
and foetus have a distinct existence as regards their nervous systems, and even 
their blood. Still, the multitude of facts which have accumulated justify the 
belief that deformity or other abnormal development of the foetus is, at times, 
due to the emotions of the mother. Some of the cases related by Dr. White- 
head in his work on hereditary diseases are very striking and difficult to 
explain on the ground of coincidence. I have met the following cases ; An 
Irish woman of strong emotions and superstitions was passing along a street 
in the first months of her gestation, when she was accosted by a beggar, who 
raised her hand, destitute of thumb and fingers, and in " God's name " asked 
for alms. The woman passed on, but reflecting in whose name money was 
asked, felt that she had committed a great sin in refusing assistance. She 
returned to the place where she had met the beggar, and on different days, 
but never afterward saw her. Harassed by the thought of her imaginary 
sin, so that for weeks, according to her statement, she was made wretched by 
it, she approached her confinement. A female infant was born, otherwise 
perfect, but lacking the fingers and thumb of one hand. The deformed 
limb was on the same side as, and it seemed to the mother to resemble 
precisely, that of the beggar. In another case which I met a very similar 
malformation was attributed by the mother of the child to an accident occur- 
ring to a near relative which necessitated amputation during the time of her 
gestation. I examined both of these children with defective limbs, and have 
no doubt of the truthfulness of the parents. In May, 1868, I removed- a 
supernumerary thumb from an infant whose mother, a baker's wife, gave me 
the following history : No one of the family and no ancestor, to her know- 
ledge, presented this deformity. In the early months of her gestation she 
sold bread from the counter, and nearly every day a child with double thumb 
came in for a penny roll, presenting the penny between the thumb and the 
finger. After the third month she left the bakery, but the malformation was 
so impressed upon her mind that she was not surprised to see it reproduced 
in her infant. Mrs. S , West Fiftieth street. New York, when in the 



MATEBXAL IMPEESSIOXS. 37 

seventh week of gestation saw a child with fingers united, so that they resem- 
bled the palm of the hand extended. She was much excited at the appear- 
ance, and clutched the window-sill with such force as to cause abrasion of 
the fingers. The malformation of the child made a deep and lasting impres- 
sion on her mind, and her child, born at term, had the index, middle, and ring 
fingers of the left hand webbed and ending with the first phalanges, while the 

little finger was normal. Mrs. D , Eighth avenue, New York, seven 

months before the birth of her child, when visiting at a distance, accident- 
ally broke the plate of a full set of upper teeth. The line o{ fracture was 
antero-posterior and through the centre of the plate. Being away from home, 
she was much annoyed by the accident, and retained the fragments of the 
plate in, situ by pressure with the tongue. As she could not open her mouth 
without the plate falling- out, except it was retained by pressure with the tongue, 
her mind was dwelling almost constantly on the accident during the few days 
of her visit. Her boy, born seven months subsequently, had a hare-lip and 
cleft palate. The mother stated that the deficiency in the lip and palate cor- 
responded precisely to the location of the fracture in the plate. Dr. G-reenley 
relates five similar cases in which infants at birth presented marks or arrested 
development corresponding in appearance with objects which produced strong 
mental impressions in the mothers (^Ainer. Prac. and Neios, Oct. 29, 1887). 

Dr. William A. Hammond of Washington, in an interesting paper on the 
"Influence of the Maternal Mind," etc. (^Quarterly Journal of Pht/dological 
Medicine^ January, 1868), says : '■ The chances of these instances, and oth- 
ers which I have mentioned, being due to coincidence are infinitesimally small, 
and though I am careful not to reason upon the principle of POST HOC, ERGO 
PROPTER HOC, I cannot, nor do I think any other person can, no matter how 
logical may be his mind, reason fairly against the connection of cause and 
effect in such cases. The correctness of the facts can only be qu-estioned ; 
if these be accepted, the probabilities are thousands of millions to one that 
the relation between the phenomena is direct." Professor Dalton also says 
(^Hmnan Physiology^ : '■ There is now little room for doubt that various deform- 
ities and deficiencies of the foetus, conformably to the popular belief, do really 
originate in certain cases from nervous impressions, such as disgust, fear, or 
anger, experienced by the mother." The observations on which this belief 
is based relate both to man and the lower animals. A very strong argument 
in its support is, as Professor Hammond remarks, the popular opinion, which 
dates back to the time of Jacob (Genesis xxx.). An almost universal sen- 
timent, running through centuries, is rarely wholly fallacious. It has some 
truth for its foundation, especially when, as in this instance, the subject is 
one of observation. 

If maternal emotions affect the development of the exterior of the foetus, 
as observations show and physiologists admit, the presumption is strong that 
they may afi"ect also the proper development and adjustment of the parts of 
the brain, an organ so complex and delicate, and may therefore give rise to 
idiocy. Dr. Seguin (^Idiocy and its Treatment^ etc., New York, 1866) thus 
remarks on this point : '■ Impressions will sometimes reach the foetus in its 
recess, cut oJBF its legs or arms, or inflict large flesh wounds before birth, . . . . 
from which we surmise that idiocy holds unknown though certain relations 
to maternal impressions as modifications to placental nutrition." 

In volume i. of the Cydopsedia of Diseases of Children (Philadelphia, 
1889) Dr. AY. C. Dabney has published the statistics of 90 cases showing 
that both mental and bodily defects in the infant sometimes result from vivid 
mental impressions in the mother during the early months of her gestation. 
These ca-ses are mostly collated from recent medical literature, and many of 
them are striking instances showing the effect of maternal impressions in 



38 



CABE OF THE MOTHER IN PREGNANCY. 



Fig. 1. 



causing malformations in the foetus, not only in the human race, but also in 
quadrupeds. Dr. Dabney also relates the remarkable statement of Baron 
Larrey, that 92 enceinte women who had experienced the extreme mental and 
physical suffering of the siege of Landau in 1793 brought forth infants with 
the following result: born dead, 16; born alive, but dying in ten months, 
33 ; born idiotic, 8 ; born with bones ununited or in a fragmentary state, 2. 
It is an interesting fact that abnormalities of structure occurring from 
whatever cause are sometimes propagated to descendants. Dr. Carpenter 
and others relate instances among the lower animals, and similar instances 
of transmission have now and then been observed in the human race. Thus, 
in the issue of Nature for March T, 1878, it is stated on the authority of M. 
Lenglen, a physician of Arras, that a certain M. Gamelon in the last century 
had two thumbs on each hand and two great toes on each foot : this peculiar- 
ity did not appear in the son, but it reappeared in the three succeeding gene- 
rations, so that some of the great- 
great-grandchildren possessed it in as 
marked a degree as their ancestors. 

In view of such important facts 
the duty of the pregnant woman is 
rendered the more imperative to avoid 
the presence of disagreeable and un- 
sightly objects, as well as all causes 
of excitement, and to remove, as soon 
as possible, vivid and unpleasant im- 
pressions by quiet diversion of the 
mind. 

The disastrous results upon the 
foetus of severe injuries received by 
the mother are well known to the 
profession, for premature labor and 
death of the child or feebleness from 
its prematurity are common results 
of such accidents. In rare instances 
the child may be so injured as to be 
deformed for life, as in the following 

interesting case: Richard L , aged 

six years, came, in January, 1877, to 
the children's class in the Bureau for 
the Belief of the Out-door Poor. The 
following history was obtained : On 
November 27, 1870, one month before the birth of Bichard, the mother fell 
heavily on the ice when stepping from a city car. Uterine hemorrhage 
resulted, which continued more or less freely, producing marked pallor, till 
her confinement, which occurred December 23d. The position of th b child 
in utero was crosswise, but nothing untoward occurred in the delivery. Imme- 
diately after its birth, when it was being washed by the nurse, a blister about 
one inch in diameter was observed on the right side of the thorax, located 
about one inch below and two and a half inches externally to the nipple. A 
cicatrix resulted, which now marks the site of the sore. When the blister 
healed the child seemed entirely well, and nothing more was thought of the 
unusual occurrence of an intra-uterine vesication till nearly half a year had 
elapsed, when the thorax below the nipple and at the site of the cicatrix was 
observed to be depressed, and the depression has continued to the extent 
indicated in the woodcut. 

The ribs at the point of depression are found to be widely separated ; the 




MORTALITY OF EARLY LIFE. 39 

rib below being pushed downward so as to form one side of the triangle, its 
cartilage the second side, and the rib above the hypothenuse. The distance 
of the perpendicular line passing from the costo-chondral articulation of the 
lower rib to the upper rib, or tTie hypothenuse, is two and a half inches by 
measurement. The depression in this triangular space evidently resulted 
gradually from the wide separation of the ribs, and the consequent loss of 
resiliency in the thoracic walls in the space destitute of bony support. The 
child lay crosswise in utero. and it seems probable that the injury was pro- 
duced by the pressure of its arm against the ribs during the fall. Cases like 
the above, and the graver cases in which foetal life is sacrificed or the child 
is born to a puny and uncertain existence from prematurity, show the very 
great importance of a quiet and regular life on the part of one who is about 
to become a mother; for bodily injuries, like unpleasant sights, occur when 
least expected. 



CHAPTER III. 

MOETALITY OF EAELY LIFE: ITS CAUSES AND PEEVENTIOK 

No fact is better known in the profession than that the first years of life 
constitute the period of greatest mortality. 

In England, where there is an accurate registration of births and deaths, 
statistics show fifteen deaths in every hundred infants in the first year of life, 
and between four and five deaths in the first month Statistics on the Con- 
tinent correspond with those in England as regards the periods of greatest 
mortality. Quetelet says :...." There die during the first month after birth 
four times as many children as during the second month after birth, and 
almost as many as during the entirety of the two years that follow the first 
year, although even then the mortality is high. The tables of mortality 
prove, in fact, that one-tenth of children born, die before the first month has 
been completed.'' 

In this country, in consequence of deficient registration of births, the 
percentage of deaths to births cannot be accurately ascertained. In this 
city 53 per cent, of the total number of deaths occur under the age of five 
years, and 26 per cent, under the age of one year. According to the census 
of 1865, there were in New York City 95.020 children under the age of five 
years, and during the five years ending with 1865, 49,000 children five years 
old and under had died. Therefore, according to these statistics, more than 
one-third of all the infants born in this city die under the age of five years. 
An error, however, occurs from the fact that, while the death-statistics were 
complete, it is known there were more children in the city than were embraced 
in the census returns. Still, it may, I think, be safely stated that one-fourth 
of the children born in this city die before the age of five years. 

In less-crowded cities and the rural districts it is known that the percent- 
age of deaths in the first j^ears of life to the total number of deaths is con- 
siderably less than in New York City, but it is nevertheless large. 

As the child advances toward puberty the liability to sickness and death 
gradually diminishes, but even the last years of childhood present a con- 
siderably larger percentage of deaths to the population than does youth or 
manhood. 

The causes of this great mortality of infants and children, and the means 
of diminishing it, deserve careful consideration. 



40 MORTALITY OF EARLY LIFE. 

Some of the causes which conspire to produce it are to a considerable 
extent unavoidable. Such are congenital vices of formation of internal 
organs. Many of the internal malformations necessarily occasion an early 
death. Cases of anencephalus, most cases of congenital hydrocephalus, of 
spina bifida, of cyanosis, are fatal before the close of infancy. These defects 
of formation we cannot detect before birth, and their causes are often obscure. 
Some of them seem to result from inflammation, believed to be, occasionally, 
syphilitic, developed at some period of foetal existence. Other internal mal- 
formations are attributable to perturbating influences operating temporarily 
on the mother during gestation. But in a large proportion of cases we can- 
not assign the cause. 0.bviously, only partial success can attend our eff"orts 
as regards prevention in these cases, and almost no success as regards the use 
of remedial measures. 

Another obvious cause of the great mortality of early life is natural fee- 
bleness of system, especially in infancy. The younger the patient prior to 
the middle period of life, the sooner are the vital powers exhausted by dis- 
ease. Hence a larger proportion of infants succumb to the same malady 
than children, and a larger proportion of children than adults. This state- 
ment is true of infancy and childhood in general. It is a law in nature, and 
cannot be changed by art. But there are many infants born with hereditary 
disease or a strong predisposition to disease through a fault which is, in a 
degree, curable, in the system of one or both parents ; as, for example, the 
syphilitic, scrofulous, or tubercular diathesis. Parents seriously afl'ected by 
such diseases cannot, without corrective treatment, have healthy off'spring. 
Their children are among the first to droop and die, either directly from the 
inherited disease, or from feebleness of constitution which such disease entails, 
and which renders them an easy prey to other diseases. The duty of the 
physician as regards such parents is obvious. He may, by therapeutic and 
hygienic measures, secure a more healthy progeny, and so far as he can do 
this he aids in diminishing the infantile mortality. He may sometimes, by 
timely measures directed to the infant, establish a better state of health. 

The subject of hereditary disease is one of great interest and importance, 
especially as regards the city population. Inherited afl"ections are less com- 
mon in the country, but in the city they contribute largely to the number of 
deaths in early life. 

Another important cause of the great mortality of children is the fact 
that they are peculiarly liable to certain severe and fatal maladies. I allude 
particularly to the acute infectious diseases, which, as a rule, occur but once, 
and that in childhood. Some of them, as scarlet fever, greatly increase the 
number of deaths. They extend and become epidemic through the inter- 
course of children. We are constantly witnessing in New York the spread 
of the acute contagious diseases, especially of whooping cough, measles, scar- 
let fever, and diphtheria, through the schools. Measures employed, thus far, 
by boards of health or other local authorities to prevent the dissemination of 
these and kindred diseases have been but partially successful, except in regard 
to smallpox. In the large public schools especially these maladies are most 
frequently contracted, and from them they radiate over the school districts ;. 
for if, as is now common, at least in New York City, a child comes to school 
wearing clothes which at home have lain in a room where a brother or sister 
was sick with diphtheria or scarlet fever, or if he enter the class with a mild 
pertussis or measles, certain of his classmates will probably return home 
infected with the virus of the disease. The same remarks are applicable, 
though with less force, to private schools. From both such schools I have 
over and over again witnessed the dissemination not only of the maladies 
mentioned, but also of the milder infectious diseases, as mumps and varicella. 



CAUSES OF INFANTILE MORTALITY. 41 

The Health Board of New York City has recently, by stringent enactments 
regulating the schools, accomplished much in suppressing this source of the 
infectious diseases. 

In hospitals and asylums for children much can be done to prevent the 
occurrence of the infectious diseases by strict surveillance and prompt isola- 
tion of all suspicious cases. Without such care scarcely a year passes in 
which these institutions are not scourged by one or more of these diseases. 
Much has been said of the crowding of families in tenement-houses so com- 
mon in Xew York and other large cities, by which a large number of children 
are brought under one roof, of the uncleanliness of person and apartment to 
which it leads, and of the insufficient air and space which it allows to each. 
But one of the strongest objections, in my opinion, to the present plan of 
building and crowding tenement-houses is the facility which it affords for the 
spread of the contagious diseases of childhood ; and it is in such houses, as 
shown by statistics, that these maladies are the most frequent and fatal. The 
much-needed enactments or regulations in relation to the construction and 
occupancy of such houses would, among other salutary effects, greatly dimin- 
ish the death-rate from the infectious maladies. 

Over the most loathsome, and formerly the most fatal, malady of man- 
kind — namely, smallpox — we now have, or can have, complete control by 
statutory enactments enforcing vaccination. It is only by carelessness or 
the lack of sufficiently stringent regulations relating to the matter that small- 
pox is not " stamped out." Again, some of the most fatal inflammatory 
diseases of life occur chiefly in childhood, as croup and capillary bronchitis. 
These and kindred diseases can only be prevented by proper hygienic man- 
agement on the part of families, and the circulation of tracts or other means 
calculated to educate families in reference to the management of children 
cannot fail to diminish the number of cases of such inflammations, and, con- 
sequently, of the deaths from them. 

Another obvious and important cause of the mortality of early life is the 
antihygienic condition or state in which many children live, in consequence 
of the poverty or gross negligence of parents. 

Residence in insalubrious localities, personal and domiciliary uncleanliness, 
exposure without proper protection to vicissitudes of weather, are fertile 
causes of sickness and death. Hence one reason for the great infantile 
mortality among the city poor, who live in damp and dark alleys and in 
crowded and filthy tenement-houses, breathing night and day an atmosphere 
loaded with noxious gases. All physicians are aware how the most fatal 
diseases, such as Asiatic cholera, cholera infantum, diphtheria, and typhus 
fever, seek the quarters of the city poor, and what terrible havoc they make 
there. All are aware, also, what wonderful recoveries result when feeble and 
attenuated infants, gradually sinking with chronic diseases, induced in great 
measure by the foul air, are transferred from such localities to the pure air 
of the country. 

Careless management of young children as regards dress increases greatly 
the liability to local diseases, such as commonly occur from exposure to cold. 
These are inflammatory affections seated chiefly upon the mucous surfaces, 
but sometimes in parenchymatous organs. Adults, aware of the effect of 
sudden change of temperature from warm to cold or of exposure to currents 
of air, protect themselves by additional clothing. Such precautionary meas- 
ures are often lacking in the management of young children, and hence one 
cause of their great liability to local affections, both of the respiratory and 
digestive organs. 

Routh, in his excellent treatise on Infant Feeding, says : '• Among the 
most pernicious influences to young children, however, we may include cold ; 



42 MORTALITY OF EARLY LIFE. 

the change of temperature from 45° to four or five below zero, as before 
stated, producing an increase of mortality in London alone of three to five 
hundred. As out of 100 deaths, however, from all specified causes, nearly 
24 occur to children under one year, and 36 to children under five, the great 
increase of mortality to children by cold is thus at once made obvious. 
Indeed, it is a household word among us, which takes its origin from the 
Registrar-Greneral's returns, that a very cold week always increases the 
mortality of the very young and the very aged." 

Lastly, a very important cause of mortality in early life is the use of 
improper food. In infants artificial feeding in place of the aliment which 
nature has provided for them, and in children the use of innutritions or indi- 
gestible articles of diet, give rise to diarrhoeal maladies, emaciation, and death 
in numerous instances. Sometimes, also, defective alimentation is the cause 
of scrofulous or tuberculous ailments, and sometimes it gives rise to a 
cachexia or feebleness of system which, without engendering any positive 
disease, renders those thus afi"ected less able to support disease induced by 
other causes. A committee, of which Professor Austin Flint, Jr., was chair- 
man, appointed in 1867 to revise the " dietary table of the children's nurseries 
on Randall's Island," states, with much truth and force : " Children .... 
are not capable of resisting bad alimentation, either as regards quantity, 
quality, or variety. At that age the demands of the system for nourishment 
are in excess of the waste, the extra quantity being required for growth and 
development. If the proper quantity and variety of food be not provided, 
full development cannot take place, and the children grow up, if they sur- 
vive, into puny men and women, incapable of the ordinary amount of labor 
and liable to diseases of various kinds." 

Improper feeding, like other causes of mortality, is much more injurious, 
much more frequently the cause of death, in the city than in the country. 
Statistics in Europe, as well as this side of the Atlantic, establish this fact. 
It is in infancy, and especially in the first year, that the use of unwholesome 
food entails the most serious consequences. No artificially-prepared food is 
a good substitute for the mother's milk, and hence artificial feeding of the 
infant, unless under the most favorable circumstances, results disastrously. 
In the country, where salubrious air and sunlight conspire to invigorate the 
system, where a robust constitution is inherited, and where cow's milk, fresh 
and of the best quality, is readily obtained, lactation is not so necessary for 
the well-being of the infant ; but in the city its importance cannot be too 
strongly urged. 

The foundlings of cities afford the most striking and convincing proof of the 
advantages of wet-nursing. In some cities foundlings are wet-nursed, while 
in others they are dry-nursed, and the result is always greatly in favor of the 
former. Thus, on the Continent, in Lyons and Parthenay, where foundlings 
are wet-nursed almost from the time that they are received, the deaths are 
33.7 and 35 per cent. On the other hand, in Paris, Rheims, and Aix, where 
the foundlings were wholly dry-nursed, at the date of the statistics their 
deaths were 50.3, 63.9, and 80 per cent. 

In New York City the foundlings, amounting to several hundred a year., 
were formerly dry-nursed, and, incredible as it may appear, their mortality 
with this mode of alimentation nearly reached 100 per cent. Now wet-nurses 
are employed for a portion of the foundlings, with a much more favorable 
result. Several years ago, before the New York Foundling Asylum existed, 
the foundlings of New York were taken care of by the pauper women of the 
almshouse, and the medical board of Charity Hospital assigned me to the 
service in the almshouse. Foundlings were received nearly every day, and 
were given cow's milk prepared by these pauper women. Incredible as it 



WEIGHT OF INFANT. 43 

may seem, the deaths corresponded with the admissions: only one infant was 
pointed out that had survived the first half year in the almshouse. 

These facts, to which others might be added from the experience of 
European cities, show the importance of wet-nursing as a means of reducing 
infantile mortality in the cities. What has been stated as regards the result 
of artificial feeding of foundlings is true, in great measure, in reference to 
all city infants. The ill-efi"ect of artificial feeding is well known in this city, 
and it is the common practice in families to employ a hired wet-nurse if, for 
any reason, the mother's milk is insufficient. 

When the infant has reached the age at which it is proper to wean, the 
digestive organs are less frequently deranged by errors of diet. More sub- 
stantial food, and considerable variety in it, may now be not only safely 
allowed, but are required by the wants of the system. In infancy, there- 
fore, the mortality is largely increased by improper diet, while in childhood 
the diet is a much less common cause of death. 



CHAPTER IV. 

WEIGHT, GEOWTH, LACTATIOX. 

Dr. K. Parker, resident physician of the Xew York Infant Asylum 
when these observations were made, weighed, immediately after birth, 170 
infants — 89 male and 81 female — born consecutively and at term, with the 
following result : 

Average male weight 7 lbs. 11 oz. 

" female " ~. 7 " 4 " 

Fifty of these, who were wet-nursed and apparently well taken care of, were 
weighed when one week old, with the following result : 

Increase of weight in 32 cases. 

Loss of weight in 13 " 

Average gain 4i-«o oz. 

" loss 3^ " 

Greatest gain . .12 " 

" loss 6 " 

AVERAGE GAIN. 

From birth to age of 4 months (25 cases) 4 lbs. 8f oz. 

" 3 to 6 months (6 cases) 3 " 3i- " 

" 6 to 9 " " 9 " 7X " 

" 9 to 12 " " 1 " 15J " 

It is desirable that the infant as soon as it requires nutriment should 
receive breast-milk. If it be fed for a few days with the bottle or spoon, 
it may be difficult finally to induce it to take the breast ; therefore it is well 
to determine early whether the mother will be able to wet-nurse her infant, 
so that, if unable, suitable provision may be made. 

The matter of determining beforehand the capability of the mother for 
wet-nursing has been investigated by Dr. Donne of Paris, and in his treatise 
on Mothers and Infants he describes the mode in which it may be ascertained. 
The desired information, in his opinion, may be acquired by examining the 



44 WEIGHT, GROWTH, LACTATION. 

colostrum, which is secreted in small quantity, in the last months of gesta- 
tion, and which can be squeezed from the breast in sufl&cient quantity for 
inspection. 

In some women, according to Dr. Donne, the colostrum is so scanty that 
only a drop or half a drop can be obtained from the nipple by careful pres- 
sure. This will be found by the microscope to contain but few milk-glob- 
ules, ill formed, and a few granular bodies, such as the colostrum ordinarily 
contains. Such women almost invariably furnish poor milk and in small 
quantity. In other women the colostrum is abundant, but thin, resembling 
gum-water ; it lacks the yellow streaks and viscous character of ordinary 
colostrum, and it flows readily from the nipple. The milk of such women 
is sometimes scanty, sometimes abundant, but it is watery and deficient in 
nutritive principles. In a third class of women the colostrum is pretty abun- 
dant, and it contains yellowish streaks of more or less consistence, which are 
found to be rich in milk-globules of good size. Women furnishing such 
colostrum in the last weeks of gestation will have sujfficient milk and of 
good quality. These latter women make the best wet-nurses. 

Wet-Nursing: its Advantages and Hindrances; Physical 
Conditions rendering it Improper. 

During the first year of the infant's life the natural mode of alimenta- 
tion — that by the mother's milk — should always be recommended, except 
in those instances in which mothers are incapacitated by physical ailments 
or mental derangement. The practice common in New York, and probably 
in other cities, of employing wet-nurses in the belief that suckling their 
infants deprives mothers of social enjoyments and by the drain upon the 
system impairs their general health, should be discouraged. Wet-nursing 
by the mother, if properly regulated, with sufficient undisturbed sleep at 
night, and with the maintenance of good appetite and digestion, does not 
impair her health, but, on the other hand, tends to promote her physical 
well-being. But there are unavoidable conditions which render wet-nursing 
by the mother injudicious or impossible. These will be considered here- 
after. 

The primipara often experiences difficulty in wet-nursing in consequence 
of a depressed state of the nipple. It is not sufficiently prominent to be 
readily grasped by the mouth, and after inefi'ectual attempts the infant 
becomes fretful when applied to the breast, and perhaps for a time refuses 
it altogether. Multiparas occasionally experience the same inconvenience, 
but it is not common when there has once been successful lactation. By 
calmness and perseverance on the part of the mother the nursling can usually 
be made to seize the nipple in the course of a week. 

Depression of the nipple is, to a certain extent, the result of pressure 
upon it by the dress during gestation. The state of the nipples should 
indeed, in those who have never suckled, receive early attention, even before 
the birth of the infant. Tightness of dress around the breast, as also upon 
every part of the body, should be avoided, and from time to time gentle 
traction should be made upon the nipple if it be depressed. It may be 
drawn out by the fingers of the mother several times each day, or by a 
common breast-pump, or by suction with a tobacco-pipe, the edge of the 
bowl having been smoothed. Occasionally, in these cases of depressed nip- 
ple the mother, fatigued and discouraged by her frequent ineffectual attempts 
to induce the infant to nurse, becomes feverish and excited, so that the quan- 
tity of her milk is sensibly diminished. The physician should assure her, as he 
usually can with confidence, that in a few days, as the baby becomes a little 



WET-NUBSiyG. 45 

stronger, there will be no difficulty in its nursing. Some women are unre- 
mitting in their endeavors to procure nursing. This should be forbidden, 
since the lack of sleep and the nervousness which such constant endeavor 
produces tend to defeat the object which they have in view, by diminishing 
the secretion of milk. Sufficient sleep, freedom from anxiety, and no more 
frequent application of the infant to the breast than is required in success- 
ful lactation should be enjoined. Occasionally, we can best succeed in pro- 
curing lactation under these circumstances of discouragement by the aid of 
another infant older, more vigorous, and better able to seize the nipple. An 
exchange of infants a few times may remedy the difficulty. 

Occasionally, suckling is rendered difficult and painful by too long delay 
before applying the infant to the breast. When the mother has rested a few 
hours after her confinement — about six in ordinary cases — lactation may com- 
mence. There is at first but very little milk, often only a few drops, but the 
secretion is promoted by nursing, s'o that the requisite amount is sooner 
obtained than when the infant is kept from the breast till the second or third 
day. If, as some physicians advise, suckling be deferred till the breasts are 
full and tender, and if, as is often the case with primiparie, the nipples are 
also tender, many mothers lack the fortitude required to allow their infants 
to obtain a sufficient amount of milk. Excoriated and fissured nipples con- 
stitute a serious impediment to wet-nursing. They are verj^ sensitive on pres- 
sure, and are long in healing. They are fully described in works which relate 
to female diseases, and their treatment pointed out. Occasionally', fissured 
nipples do harm to the infant by the blood which escapes and is swallowed 
with the milk. A case is related in which positive indigestion was caused 
in this way, the infant vomiting, after each nursing, milk mixed with blood. 
The local hindrances to lactation described above can in most instances be 
relieved in the course of a few weeks. To what extent menstruation and 
pregnancy are detrimental to the nursing, and therefore contraindicate lacta- 
tion, will be considered in another section. 

There is occasionally a constitutional state of the mother which necessi- 
tates either the employment of a hired wet-nurse or weaning. This is the 
case when there is a strong tendency to tuberculosis. If the complexion be 
jDallid, the system at all emaciated, and suckling be attended by more or less 
exhaustion, and if with fair trial of wine and tonics no improvement follow, 
the physician is justified in forbidding further attempts at wet-nursing. If, 
under such circumstances, an hereditary tendency to tuberculosis exist, it is 
his duty positively to interdict nursing. The opinion of the physician in such 
a matter should be formed after mature deliberation. There are many women 
who, suffisring temporarily from illness and discouraged, are ready at once to 
abandon their infants to the care of others with the least encouragement on 
the part of the physician to do so, but who, by attention to their own health, 
and especially by taking more sleep, soon recover from their depression and 
become good wet-nurses. On the other hand, night-sweats, a cough, and pro- 
gressive decline in health show the need of immediate suspension of wet- 
nursing. 

Sometimes women prior to pregnancy present indubitable evidence of 
tuberculosis, but by the improved general health which attends pregnancy 
the disease is temporarily arrested. Such women should never suckle their 
infants. If they do, they . soon lose all that was gained and the disease 
advances rapidly. These objections to wet-nursing in such a state of health 
apply to the mother. There are also objections as regards the infant. The 
milk of those in decidedly infirm health is deficient in nutritive principles. 
Their infants, therefore, are ill-nourished, and if they have inherited a pre- 
disposition to tuberculosis there is great danger that this disease will be 



46 WEIGHT, GROWTH, LACTATION. 

developed in them ; whereas with healthy wet-nursing even a strong predis- 
position may remain latent. M. Donne relates the following instructive cases, 
which show the danger which sometimes attends suckling and the imperative 
necessity which may arise of discontinuing it : "A very light-complexioned 
young mother, in very good health and of a good constitution, though some- 
what delicate, was nursing for the third time, and, as regarded the child, 
successfully. All at once this young woman experienced a feeling of 
exhaustion. Her skin became constantly hot; there were cough, oppression, 
night-sweats ; her strength visibly declined, and in less than a fortnight she 
presented the ordinary symptoms of consumption. The nursing was immedi- 
ately abandoned, and from the moment the secretion of milk had ceased all the 
troubles disappeared." "A woman of forty years of age .... having lost, 
one after another, several children, all of whom she had put out to nurse, 
determined to nurse the last one herself. .... This woman, being vigorous 
and well built, was eager for the work, and, filled with devotion and spirit, 
she gave herself up to the nursing of her child with a sort of fury. At 
nine months she still nursed him from fifteen to twenty times a day. 
Having become extremely emaciated, she fell at once into a state of weak- 
ness from which nothing could raise her, and two days after the poor woman 
died of exhaustion." 

A very similar case recently occurred in my practice. A young and 
healthy woman from the countr}^, suckling her second infant, on coming to 
the city lived in a dark and very imperfectly ventilated room on the first floor 
and in the rear of a crowded tenement-house. She soon lost her appetite, 
but continued suckling for three months, when she became so anaemic and 
feeble that she was compelled to seek medical advice. She died without local 
disease, notwithstanding the most nutritious diet and free use of stimulants 
and tonics. 

Constitutional syphilis in the mother does not contraindicate wet-nursing. 
It is probable that the infant also has it. The mother should take antisyph- 
ilitic remedies, which will eradicate the disease in herself, and also, if it be 
present, in the infant. Febrile afi'ections also do not in general contraindicate 
wet-nursing. They may, however, for a time diminish the quantity of milk 
or impair its quality. If, however, the mother be in a critical state or much 
reduced, whatever the disease, suckling should cease. Whether or not the 
infant should be taken from the breast if the mother be suffering from one 
of the essential fevers depends on the severity of the malady and the degree 
of her exhaustion. Twice I have known newly-born infants to be suckled by 
mothers while the latter had scarlet fever, without contracting it, but sufi"er- 
ing immediately afterward from protracted and severe eczema. In rural 
localities, where artificially-fed infants, as a rule, do well, it might be best to 
wean if the mother have such a disease ; but in the city eczema is less dan- 
gerous than the diarrhoeal afi'ections which early weaning is likely to entail. 
In most cases of typhus and typhoid fevers weaning or procuring a wet- 
nurse is necessary, on account of the depression of the vital powers which 
these diseases produce. Mothers with organic diseases, of whatever kind, 
which impair the general health or diminish the appetite, should never be- 
allowed to wet-nurse their infants. Wet-nursing under such circumstances is 
likely to aggravate the disease, and the milk which such mothers furnish, 
even if sufficient in quantity, is deficient in nutritive properties. 

Inflammatory affections, unless of a dangerous character, do not ordinarily 
interfere with wet-nursing, except that the quantity of milk is somewhat dimin- 
ished. In severe inflammation it may be so necessary to husband the strength 
or to keep the patient perfectly quiet that suckling her infant would be inju- 
dicious. It should then be transferred to a wet-nurse or weaned. Inflam- 



WET-XUBSiyG. 47 

mation of the breast often presents an impediment to lactation. It is a 
common and painful affection, suspending or greatly diminishing the secretion 
of milk in the affected gland. Wet-nursing should cease as soon as there are 
evident signs of inflammation, unless it be limited to a small part of the 
gland. G-eneral heat of the breast, with tenderness and induration extend- 
ing over a considerable part of it, indicates the need of the immediate 
removal of the infant from it. Suckling must be restricted to the unaffected 
side. It is often the case that the volume of the inflamed gland is con- 
siderably increased from the afflux of blood to it and from the interstitial 
exudation, while it contains little or no milk, and attempts at suckling under 
such circumstances are injurious to the mother as well as to the infant. The 
cause of the swelling should be explained to the mother, who commonly 
attributes it to the accumulation of milk, and worries herself and the infant 
by attempts to make it nurse. As the inflammation abates by resolution, or 
more commonly by suppuration, and the normal secretion returns, the first 
milk, which is usually thick and stringy, should be rejected, after which the 
infant may nurse as usual. Occasionally, the abscess which has formed in 
the breast connects with a lactiferous tube, so that pus may, on suction, 
escape from the nipple. If this occur, of course nursing should be inter- 
dicted until pure milk is obtained. Pus in the milk can sometimes be 
detected by the naked eye. It presents a yellowish or greenish color, occur- 
ring in streaks when not intimately mixed with the milk. When it is inti- 
mately mixed and in small quantity, it cannot be detected by the naked eye, 
but the microscope reveals the pus-globules. M. Donne relates a case in 
which he discovered these globules by the microscope, although there were 
at first no other evidences of an abscess, and doubts were expressed in refer- 
ence to the accuracy of his observation. Finally, an abscess pointed and 
discharged. 

Sometimes when the inflammation abates the secretion does not return, 
and, worse still, occasionally the inflammation has occurred so near the nipple 
that the lactiferous tubes are permanently closed by it, so that, though milk 
form in the breast, there is no escape for it. Thenceforth onl}^ one breast can 
be used. 

If erysipelas occur in the mother, the infant should be immediately taken 
from her breast and from her arms. If this disease should not be communi- 
cated to the infant through the milk or through fissures in the nipple, of 
which there is danger, still the milk usually undergoes such a change in con- 
sequence of the erysipelas as to endanger the health of the child. Thus, one 
of the wet-nurses in the New York Infant Asylum sickened with severe facial 
erysipelas on the 24th of April, 1875, eight days after the death of her baby. 
She was wet-nursing a foundling, aged seven weeks, at the time of the com- 
mencement of the erysipelas, and, as it was very important that her milk 
should be preserved for the coming hot months, it was deemed best to allow 
the nursing to continue, the infant being placed in a crib at a little distance 
as soon as it dropped the nipple. On the 27th the baby was troubled with 
diarrhoea. April 28th its morning temperature was 101°, and that of the 
evening 103°, the diarrhoea continuing. It was now removed entirel}^ from 
the breast and was given artificial food. On the 29th there was a decided 
general icteric hue of the infant's surface, which continued till its death on 
May 1st. The stools numbered about eight daily till April 30th, when they 
ceased. The record which I preserved does not state whether there was 
vomiting, but it had probably been slight on account of the speedy prostra- 
tion. Death occurred from exhaustion. At the autopsy from half an ounce 
to one ounce of pus was found in the peritoneal cavity, newly-formed fibrin 
was observed upon the spleen and liver, and the peritoneum generally had 



48 



WEIGHT, GROWTH, LACTATION. 



lost much of its lustre : a careful microscopic examination of the liver and 
its ducts, made by Dr. Heitzmann, revealed no anatomical change which 
would explain the icteric hue, and it seemed probable that this was due 
to the altered state of the blood. The mucous membrane of the intestines 
exhibited vascular streaks and its follicles were distinct. The lesions, there- 
fore, indicated intestinal catarrh. Nothing unusual was observed in the heart 
and lungs of the infant. Its life had been , apparently sacrificed by the 
unhealthy nursing. 

Colostrum. 

The milk secreted during gestation, and immediately after the birth of 
the infant, ordinarily differs in its gross appearance, as well as chemical and 
microscopical characters, from that which is subsequently secreted. It. is 
termed Colostrum. It has a turbid and yellowish appearance, and is some- 
what viscid. It is decidedly alkaline, and undergoes lactic-acid fermentation 
more readily than common milk, and it also contains more solid matter. It 
has an excess of fat, of salts, and, according to Simon, also of sugar. It 
appears from Simon's analysis that the solid matter of colostrum is about 17 
per cent., while that of the ordinary breast-milk is about 11 per cent. 

Examined by the microscope, the colostrum is seen to contain oil-globules 
and a viscid substance which often assumes an ovoid or globular form, but 
which also exists in irregular masses of considerable size. This substance 
has been thought by some to be mucus, but it is dissolved by acetic acid and 
potash and is tinged yellow by a watery solution of iodine. It is therefore 
to be regarded as albuminous. Imbedded in this substance are oil-globules, 
which are for the most part of small size, while the free oil-globules of 
colostrum are larger than those occurring in healthy milk. The viscid sub- 
stance, with the imprisoned oil-globules, constitutes what has been designated 
the " colostrum-corpuscles." Some have erroneously considered the " colos- 
trum-corpuscles " to be compound granular cells. The compound granular 
cell or corpuscle is a cell which has undergone fatty degeneration. It is dis- 
tended with oil-globules to perhaps twice or thrice its normal size. On the 
other hand, examination of the " colostrum-corpuscles " fails to detect a cell- 
wall, and the large and irregular size of some of these corpuscles negatives 
the idea that they are cells. The oil-globules contained in the viscid substance 
are more readily acted on by ether than are the free oil-globules. 

The colostrum is replaced by milk of the normal character in six to eight 
days, sometimes as early as the third or fourth day after delivery. In excep- 



FiG. 2. 



Fig. 8. 



©a 
© - 



Oo oo 



o°<2» 






r 




Milk-sflobules. 



Colostrum-corpuscles 



tional instances the colostrum does not disappear for several weeks, and it 
may reappear at any time subsequently as a consequence of derangement of 



HmiAX MILK. 49 

the system or from disease. It is assimilated witli difficulty by the digestive 
organs of the infant, producing usually a laxative effect. It therefore aids 
in the removal of the meconium, and, being a normal secretion, it is to be 
regarded as beneficial in the first vreek of the infant's life. Continuing longer 
than the first week, its efi"ect is deleterious. It produces evident derange- 
ment of the digestive organs, and the infant that habitually nurses it never 
thrives. It has diarrhoea or vomiting, becomes more or less emaciated, and 
suffers from colicky pains. Sometimes an extreme degree of exhaustion is 
reached before the cause is suspected, for if the milk be pretty abundant the 
admixture of colostrum with it cannot be detected by the naked eye. The 
microscope alone reveals it. The following is an interesting example of this 
fact : In 1868 an infant six weeks old was brought to me with the following 
history : The mother had for several years been troubled with dyspeptic 
symptoms, but had otherwise been in good health. The infant at birth was 
fleshy and strong, but after the first week it had never thrived like other 
infants. It nursed regularly, and the quantity of milk was apparently suf- 
ficient, but it vomited as soon as it ceased nursing ; it was much emaciated 
and the bowels were habitually constipated. The digestive organs of the 
infant had been in this unhealthy state, with little variation, from the first 
week, and it was very evident, from the emaciation and exhaustion, that it 
must soon perish unless some change were efi"ected. The milk of the mother 
presented the usual appearance to the naked eye, but under the microscope 
colostrum-corpuscles were observed. A wet-nurse was immediately obtained, 
and from that moment the gastro-intestinal symptoms disappeared, with a 
rapid recovery. This case shows at once the evil effects of the colostrum 
and the need of a microscopic examination of the milk whenever the nursling- 
suffers from indigestion. 

Human Milk. 

Foster says that •• milk is the result of the activity of certain protoplasmic 
cells forming the epithelium of the mammary gland. So far as we know, the 
fat is formed in the cell through a metabolism of the protoplasm. Micro- 
scopically, the fat can be seen to be gathered in the epithelium-cell in the 
same way as in a fat-cell of the adipose tissue, and to be discharged into the 
channels of the gland either by a breaking up of the cells or by a contractile 
extrusion very similar to that which takes place when an amoeba ejects its 
digested food." Foster likewise states that there is also evidence that the 
casein and sugar are formed from the protoplasm in the mammary cells, and 
not by appropriation of the casein and sugar introduced into the system in 
the food. Therefore, if the food contain no fat, casein, or sugar, still these 
substances are produced by the cell-agency in the mammary gland (Archw 
fur Plujs., 1886, 539). 

The specific gravity of human milk is about 1032. It has been carefully 
analyzed by different chemists with nearly the same result. The following 
table, prepared by MM. Vernois and Becquerel, gives the proportion of the 
various ingredients in 1000 parts : 

Water 889.08 

Sugar 43.64 

Casein and extractive . 39.24 

Butter 26.66 

Salts (ash) ' . 1.38 

1000.00 

Recently, Prof. Albert R. Leeds has analyzed forty-three samples of 
hiealth}^ human milk, with the following results : 

4 



50 WEIGHT, GROWTH, LACTATION. 

Average. Miniinura. Maximum. 

Specific gravity 1.0317 1.030 1.0353 

Water 86.766 83.34 89.09 

Total solids . - 13.234 10.91 16.66 

Total solids not fat 9.221 6.57 12.09 

Fat 4.013 2.11 6.89 

Milk-sugar 6.997 5.40 7.92 

Albuminoids 2.058 0.85 4.86 

Ash 0.21 0.13 0.35 

It is seen that the constituents of healthy human milk vary considerably 
in different women, especially the albuminoids, which are the nutritive part. 
Leeds found all the samples alkaline except one, which was neutral. The 
heat-producing constituents, the carbohydrates, fat, and sugar vary less than 
the albuminoids. Although human milk seems thinner than cow's milk, it 
nevertheless contains more solids and less water, and has a greater specific 
gravity. Milk-sugar is its largest solid constituent. Both the sugar and the 
fat are in greater proportion than in cow's milk, while the amount of albu- 
minoids is much less. A very important difference between woman's milk 
and cow's milk is in the casein — not only in the quality, but quantity. The 
casein of cow's milk coagulates in large, firm masses, digested with difficulty 
by the infant, and its quantity is nearly five times greater than that in human 
milk, as we see by the following analysis of Prof. Leeds. Leeds found the 
average specific gravity of cow's milk 1029 : 

Woman's Milk. j Covds Milk. 

Mean. Minimum. Maximum, i Mean. Minimum. Maximum. 

Water 87.09 83.69 90.90 I 87.41 80.32 91.50 

Total solids . . . .12.91 9.10 16.31 i 12.59 8.50 19.68 

Fat 3.90 1.71 7.60 | 3.66 1.15 7.09 

Milk-sugar .... 6.04 4.11 7.80 I 4.92 3.20 5.67 

Casein 0.63 0.18 1.90 { 3.01 1.17 7.40 

Albumen 1.31 0.39 2.35 0.75 0.21 5 04 

Albuminoids . . . 1.94 0.57 4.25 | 3.76 1.38 12.44 

Ash 0.49 0.14 ? I 0.70 0.50 0.87 

Milk, being the sole food of early infancy, contains all the nutritive prin- 
ciples which are required for the growth and repair of the different tissues. 
Most of the salts which occur in the tissues exist primarily in the milk. 
Phosphate of lime, phosphate of magnesium, phosphate of the peroxide of 
iron, chloride of potassium, and chloride of sodium, known to exist in cow's 
milk, are believed to occur also in human milk. Epithelial cells are some- 
times present, derived from the lining membrane of the lactiferous tubes. 

Modification of Milk in Consequence of the Diet. 

The relative proportion of the different ingredients of the milk varies 
according to the diet. If the diet be poor, the amount of water increases 
and that of butter and casein diminishes. Lehmann says (^Phys. Chemistry, 
vol. ii. p. 65) : " From experiments made on bitches it would appear that a 
vegetable diet renders the milk richer in butter and sugar, while the solid 
constituents are augmented when a sufficient quantity of mixed food is given. 
Peligot found the milk of an ass most rich in casein when the aninial had 
been fed on beet-root, while it was richest in butter when the food had con- 
sisted of oats and lucerne. Boussingault found the milk of a cow richer in 
casein when the animal had been fed on potatoes than when other food was 
taken. Reiset found that the milk of cows which were at grass was much 
richer in butter than when the animals had stood all night in their stall with- 



MODIFICATION OF MILK BY AGE, ETC. 51 

out food ; but Playfair found, on the contrary, that the quantity of butter in 
the milk increased during the night as much as during their stall-feeding, but 
that the quantity of butter in the milk was considerably diminished by the 
motion of the animals in the fields."^ Simon made the following analysis of 
the milk of a poor woman. She was suddenly, during the period of lactation, 
deprived of the means of support, so that her food was insufficient in quantity 
and of poor quality. The amount of her milk was not diminished by priva- 
tion, but the solid constituents were reduced to 86 parts in 1000. After this, 
for a time, her diet was nutritious and abundant, the quantity of milk was 
increased, and the solid constituents amounted to 119 parts in 1000. Her 
diet was again reduced, with a reduction of the solid elements to 98 in 1000, 
and at a later period the diet was again nutritious, with an increase of the 
solid elements to 126, The chief variation observed in the milk of this 
woman was in the amount of butter. 

Modification of Milk from its Retention in the Breast. 

M. Peligot has clearly demonstrated that the longer milk is retained in 
the breast the more watery it becomes. This is explained on the supposition 
that the solid portion is first absorbed. Therefore, the milk is richer the more 
frequently it is removed from the breast. A similar fact, which has the same 
explanation, has long been known — namely, that the first milk taken from the 
breast is thinnest, while that which flows last is richest. That first removed 
has remained longest in the gland, while that which comes last is but recently 
secreted. 

A knowledge of this fact is of considerable practical importance. The 
milk, as M. Donne has shown, may be too rich, so as to cause indigestion, 
with more or less enteralgia, in the infant. Some nurslings, if the milk be 
too rich and abundant, reject a part of it by vomiting, but others do not, and 
sufi'er the consequence in derangement of the digestive organs. For such 
cases the remedy is to give the breast less frequently, by which a less amount 
of milk is taken and milk of a poorer quality. On the other hand, if there 
be poverty of the milk and the infant be insufiBciently nourished, the milk is 
more nutritious if the nursino; be at short intervals. 



Modification of Milk by Age and by Mental Impressions. 

The composition of milk varies also according to the age of the infant. 
Simon analyzed the milk of a woman at intervals for the period of about six 
months. In this case the amount of casein at first was small, but the quan- 
tity increased during the two months succeeding delivery, after which it was 
nearly stationary. A similar increase was observed in reference to the saline 
substances. The sugar, on the other hand, diminished in quantity as the 
infant grew older, its maximum amount being in the first and second months. 
The quantity of butter in the milk varies from day to day more than the 
other elements. 

Many observations have been published which show that the composition 
of the milk may be materially changed by mental impressions. The infant 
has died suddenly in the act of nursing after his mother had been violently 
excited. Such a case is related by Tourtnal. The infant ceased nursing, 
gasped, and died in the mother's lap. In other cases convulsions have 
occurred. MM. Becquerel and Yernois made the chemical analysis of the 
milk of a woman in a state of nervous excitement, and found that the solid 

^ Animal Chem., Sydenham Soc.'s trans., vol. ii. p. 55. 



52 WEIGHT, GROWTH, LACTATION. 

constituents were diminished to 91 parts in 1000, the most marked diminu- 
tion being in the butter, which was only about 5 parts. In a case related by 
Parmentier and Deyeux the milk became watery and viscid, and remained so 
till the nervous attacks from which the patient suifered had ceased. Dairy- 
men are well aware how ill-treatment and the separation of the calf from the 
cow diminish the milk which she yields. A new milkman seldom obtains as 
much milk as one with whom the cow is familiar. Bouchut, alluding to the 
influence of the moral affections on the secretion of milk, makes the follow- 
ing remark, the truth of which most mothers will acknowledge : '' It is also a 
fact that the sight of the nursling, the idea of seeing it at the breast, and the 
joy which certain mothers thence experience, exercise a moral influence over 
the secretion of the milk entirely independent of their will. They feel the 
draught of milk as soon as they behold their child or think of it too deeply ; 
and in a woman who saw her child fall to the ground the flow of milk ceased, 
and did not reappear until the child, having quite recovered, attempted to 
take the breast." 

Rotch states that a primipara of an excitable and nervous temperament 
was in a marked degree anxious and despondent in reference to her infant, 
which she was wet-nursing. The infant began to suffer from indigestion, so 
that the mother's milk was analyzed with the following result : water, 89.17 ; 
fat, 0.62 ; sugar, 5.80 ; albuminoids, 4.21 ; ash, 0.20. This marked varia- 
tion from normal milk was apparently due to the emotions of the mother. 
A wet-nurse was procured and the infant did well. 

Modification of Milk by the Catamenial Function, Preg- 
nancy, AND Other Causes. 

The catamenia reappear in most women before the close of lactation, often 
by the fifth or sixth month after delivery. If this function be re-established 
in the normal manner — that is, without any derangement of the system, with- 
out pain or undue profuseness — no unfavorable result ordinarily occurs with 
the infant. On the other hand, if the mother suffer any disturbance of the 
system or if the menses be profuse, the lacteal secretion may be so changed 
that the infant is injuriously affected by it. The symptoms produced are 
those of indigestion, such as abdominal pains, more or less vomiting, and 
diarrhoea. This result is, however, in my experience, quite exceptional. In 
rare instances more dangerous symptoms occur in the infant. A case has 
been reported to me in which at each catamenial period the nursling was 
seized with convulsions. 

Charles Marchand found in three chemical analyses of the milk during 
menstruation a diminution of 2 to 4 parts in the butter, of 2 to 5 parts in 
the sugar, and a diminution in the casein and albumen of 2 to 5 parts. This 
seems but a trifling change when we recollect that human milk in the state 
of health contains, according to the analysis of M. Robin and others, 25 to 
37 parts of butter, 37 to 49 parts of sugar, and 29 to 39 parts of casein in 
1000 of milk. Rotch has made the following analyses of the milk of two 
women during the catamenia. Their infants exhibited symptoms of indi- 
gestion during, but not before or after, the catamenial flow : 

First Case. Second Case. 

Fat 0.62 1.37 

Sugar 5.80 6.10 

Albuminoids 4.21 2.78 

Ash .20 0.15 

Solids 10.83 10.40 

Water 89.17 89.60 

{Cyclop, of Diseases of Children, 1889.) 



MOniFICATIOX OF MILK BY THE CATAMEXIAL FUXCTIOX. 53 

In these two instances the albuminoids were increased. But even if the- 
infant suffer from indigestion during the catamenial period, its duration is so 
short and the milk so soon returns to its normal state that the occurrence of 
the catamenia does not indicate the need of weaning if the infant be under 
the age of ten months. But if the menses reappear with regularity when 
the infant has attained the age of ten or twelve months, they should be con- 
sidered as designed to supersede the secretion of milk, which, indeed, usually 
begins to diminish. Weaning is then proper. If the menses return early in 
the period of lactation and give rise to symptoms in the infant in consequence 
of the altered quality of the milk, it is best to allow but little nursing during 
the catamenia, and to employ artificial feeding instead until the flow of blood 
ceases. 

The change produced in the milk by pregnancy is. in general, more inju- 
rious to the nursling than that caused by the reappearance of the menses. 
The milk of the pregnant woman frequently contains more or less of the 
viscid substance which characterizes colostrum. Still, the milk of pregnancy 
does not ordinarily derange the digestive function as much as colostrum in 
the first weeks of lactation, for pregnancy rarel}^ occurs till after the infant 
is five or six months old, when the organs of dige.^rion are less readily dis- 
turbed. The injurious effect of pregnancy on the infant is shown by vomit- 
ing or diarrhoea, by restlessness and occasional abdominal pains ; in fine, by 
symptoms of indigestion. In many cases, however, these symptoms do not 
occur, and the infant, though nursing regularly, continues to thrive. No 
doubt, as a rule, the nursling should be weaned when there are clear evi- 
dences of pregnancy, but under certain circumstances weaning is injudicious. 
I have on different occasions been called to infants in midsummer dangerously 
sick with diarrhoeal attacks induced by this cause. These infants were per- 
haps doing well or suffering but little from indigestion, when the mothers, 
suspecting themselves pregnant, at once withdrew them from the breast, and 
cholera infantum or a kindred disease was the result. No infant in the city 
should be weaned in the hot months. It is much safer, though there be 
indubitable signs of pregnancy, that it continue nursing till the cold weather. 
The better method is, however, under such circumstances to employ a wet- 
nurse or to remove the infant to the country and wean it there. In cold 
weather it is usually safe to wean an infant in the city after it has reached 
the age of five or six months. 

Sometimes a young mother devotes herself unremittingly to the care of 
her infant, giving it the breast every hour or oftener through the day and 
frequently through the night. She gives the infant little rest, and has but 
little herself. This devotion, praiseworthy as it is, is nevertheless very 
injurious to both parties concerned. The rule should be repeated and remem- 
bered, that while an infant may nurse hourly during the first month, except 
in the hours which the mother requires for sleep, in which it should not nurse 
more than once or twice, after the first month nursing should be restricted to 
intervals of two hours till the third or fourth month, and in older infants, 
with greater capacity of the stomach, to intervals of three or four hours. 
Too frequent nursing produces indigestion with its usual fretfulness and 
diarrhoea, and it deprives the mother of the mental composure and rest which 
are required for successful lactation ; but the more the infant frets, in many 
instances, the oftener the mother applies it to the breast, which only increases 
the indigestion. AVorriment and lack of sleep tend not only to diminish the 
milk, but also to impair its quality. 

Venereal excesses have a very injurious effect on the character of the 
milk. In our remarks on the hygienic treatment of the summer diarrhoea of 
infants we allude to authenticated cases in which excesses of this kind caused 



54 WEIGHT, GROWTH, LACTATION. 

fatal intestinal catarrh in the nurslings. Again, the relative proportion of 
the ingredients in the milk may habitually vary from the normal without any 
assignable cause, so as to be injurious to the infant. Habitual ill-health, as 
from phthisis, anaemia, syphilis, or severe nervous disorder, sometimes so 
affects the secretion of milk as to render it unsuitable for the infant. It may 
cause a reappearance of the colostrum, like that immediately after parturition. 

Effect of Medicines on the Mother's Milk. 

This important subject has been investigated by Fehling (^Arch. f. Gyn.^ 
xxvii. p. 332 ; Jour, de Med.., July 31, 1887). According to him, one to two 
grammes of salicylate of sodium, taken by a woman who is wet-nursing, may 
be in part recovered in the child's urine. Rheumatism in the nursing child 
may therefore be treated by the ordinary doses of this agent administered to 
the mother. Rheumatism occurs more frequently in the nursing infant than 
is commonly supposed, since its symptoms as regards the joints are usually 
mild and likely to be overlooked, and it often causes endocarditis and per- 
manent valvular disease when its presence is not suspected and no physician 
is called. Schaeffer relates the case of an infant born with rheumatism. 
Iodide of potassium also, says Fehling, given to the mother, can be detected 
in large quantity in the infant's urine. We have Fehling's authority for the 
following statements : After applying iodoform to perineal lacerations, iodine 
was found in the milk and urine of the mother, but no apparent harm has 
resulted from applying iodoform to wounds or sores in the nursing mother. 
Mercury taken by the mother did not appear in the milk, and the same was 
true of acetic, hydrochloric, and citric acids. Therefore acid foods probably 
do not render the milk acid. Laudanum given by the mouth in no instance 
caused drowsiness in the infant, and morphia given hypodermically did not, 
as a rule, affect the child. On the other hand, atropine taken by the mother 
caused dilation of the infant's pupils. Hydrate of chloral taken by the 
mother did not affect the child. The effect on the nursing child of medi- 
cines administered to the mother needs further investigation. The observa- 
tions relating to it published in the journals are as yet too meagre for the 
valid and reliable deductions which are required by the profession to ensure 
safe and proper medication of nursing women. 

Differences in Women as regards Quantity and Quality 

OF Milk. 

There is a great difference in different women as regards the quantity and 
quality of their milk, and even the mode in which it is secreted. The best 
wet-nurses are usually robust without being corpulent. Their appetite is 
good, and their breasts are distended from the number and large size of the 
blood-vessels and milk-ducts. There is but a moderate amount of fat around 
the gland, and tortuous veins are observed passing over it. Such nurses do 
not experience a feeling of exhaustion and do not suffer from lactation. 

The nutriment which they consume is equally expended in their own sus- 
tenance and the supply of milk. There are other good wet-nurses who have 
the physical conditions which I have described, but whose breasts are small. 
Still, the infant continues to nurse till it is satisfied, and it thrives. The milk 
is of good quality, and it appears to be secreted mainly during the period of 
wet-nursing. Other mothers evidently decline in health during the time of 
nursing. They furnish milk of good quality and in abundance, and their 
infants thrive, but it is at their own expense. They themselves say, and 
with truth, that what they eat goes to milk. They become thinner and paler, 



SCANTINESS OF MILK. 55 

are perhaps tioubled with palpitation, and are easily exhausted. They often 
find it necessary to wean before the end of the usual period of wet-nursing. 
There is another class whose health is habitually poor, but who furnish the 
usual quantity of milk without the exhaustion experienced by the class 
which I have just described. The milk of these women is of poor quality. 
It is abundant, but watery. Their infants are pallid, having soft and flabby 
fibre. All these kinds of wet-nurses are met in practice. 

Occasionally, a considerable part of the milk is lost by oozing from the 
breast. This sometimes occurs in robust women, but is more frequently asso- 
ciated with weakness. It is then due to a relaxed state of the orifices of the 
milk-ducts. Galactorrhoea, as the excessive secretion and flow of milk are 
designated, is said to be often associated with a menorrhagic diathesis ; that 
is, women whose menses have been profuse are apt to have too abundant a 
flow of milk, corresponding with the menorrhagia. It is said that galactor- 
rhoea is also apt to occur in those who are subject to discharges from parts 
which sustain no immediate relation to the breast, as in cases of hemorrhoidal 
flux, diabetes insipidus, etc. Excitement or irritation of the uterus or ovaries 
may serve as an exciting cause of galactorrhoea in those predisposed to it, and 
excessive suckling may have the same eff'ect. 

Rules in regard to Suckling. 

Newly-born infants should be applied to the breast about twelve times in 
twenty-four hours. The suckling should be mostly in the day-time, and only 
once or twice during the hours required by the mother for sleep. After the 
third or fourth week the infant should take the breast at intervals of two 
hours during the day-time, and only once during the seven or eight hours of 
sleep which the mother must have in order that her health be preserved and 
her milk be of good quality. A healthy infant empties the breast in ten to 
fifteen minutes of nursing, when it should be removed, and if in good condi- 
tion it falls asleep, and may not awaken until the next suckling, or if it 
remain awake it is cheerful and contented. It is a fact not generally known 
by the laity that frequent nursing — as, for instance, every half hour — renders 
the milk too concentrated. It increases the solid constituents above the nor- 
mal. On the other hand, if the infant be applied to the breast at long inter- 
vals, the proportion of solids in the milk is diminished below the average, and 
the water is in a corresponding degree increased. Knowledge of this fact has 
its practical application. A mother with a fretful infant, having indigestion, 
usually applies it often to the breast, and her milk in consequence becomes 
too concentrated and is digested with difficulty. In order that the ingredients 
in the milk be in the proper proportion for healthy digestion, not only should 
the mother lead a quiet life, with regular meals of plain but nutritious food, 
but suckling should be at intervals of about two or three hours. 

Scantiness op Milk: its Causes and Treatment. 

Though the amount of breast-milk which the infant requires is less than 
was estimated by Gumming, still insuflaciency of this secretion is not uncom- 
mon, especially in cities. According to the statistics of Drs. Merei and 
Whitehead, among healthy mothers there is insufficiency in 16.5 per cent., 
while among mothers in feeble health the percentage is 46.6. In treating 
of this subject in the following pages reference is not had to those cases in 
which there is temporary diminution of milk from acute diseases or other 
perturbating causes, but to those cases in which there is habitual scantiness. 

One cause of scanty secretion of milk is a life of privation or of daily 



56 WEIGHT, GROWTH, LACTATION. 

work, which necessitates separation from the infant. Insufficient food may- 
render the milk more watery, as has already been stated, or it may cause 
diminution in its quantity. The mother thus situated is pallid. She is sub- 
ject to palpitation and attacks of faintness. Her condition, indeed, is that 
of anasmia. Working women have scantiness of milk, not only in conse- 
quence of hardships, but also because they are usually separated for hours 
from their infants. Age is also a cause of scantiness of milk. Mothers at 
the age of forty years ordinarily furnish less milk than between twenty and 
thirty. Those who have not borne children till late in life, and whose mam- 
mary glands have therefore long been inactive, have less milk than those who 
commence bearing children at the usual period. 

Routh speaks of hypersemia as a cause of defective lactation. " This is 
a variety," says he, " which I have chiefly observed among hired wet-nurses 

selected from the poorer classes and admitted into wealthier families 

When feeding at the expense of a master or mistress the amount they devour 
often surpasses all moderate imagination. They, in fact, gormandize. If in 
such instances a wet-nurse be given all she asks for, she will be found often 
to eat quite as much as any two men with large appetites ; and as a result she 
becomes gross, turgid, often covered with blotches or pimples, and generally 
too plethoric to fulfil the duties of her position. The plethora, as first 
induced, is of the sthenic variety, but it soon assumes an asthenic character, 
and as the immediate result the breast no longer secretes its quantity of 
milk. There may be good milk secreted, but it is in small quantity, and this 
quantity diminishes daily. The breast may also enlarge, but it is from a 
deposition of fatty tissue in and about it, as in other parts of the body. The 
veins on the surface become less apparent — always a bad feature in a suckling 
breast — till finally the flow of milk ceases altogether." 

Atrophy of the breast from the employment of iodine or from long disuse 
is also a cause of insufficiency of milk. 

It is so necessary for the health and development of the infant that the 
milk should be in proper quantity as well as quality that it is best in a work 
of this kind to consider the treatment of insufficient secretion, and, on the 
other hand, of excessive secretion and loss of milk, or galactorrhoea ; and first 
of insufficient or scanty secretion. 

The most efficient mode of increasing the lacteal secretion is that which 
is also natural — namely, suction from the nipple. There are many cases on 
record in which this has produced the flow of milk in women who have never 
borne children, and even in men. Baudelocque mentions the case of a girl 
eight years old who suckled her brother for a month, and cases at the opposite 
extreme of life have been reported — one of a woman of seventy years who 
wet-nursed a grandchild twenty years after her last confinement. 

The following case, which was under my observation, is interesting in this 

connection : Lizzie S was confined with her first child on May 30, 1876. 

When the baby was a few days old, and before she had left the bed, she had 
inflammatory symptoms which proved to be due to pelvic cellulitis. Its 
course was tedious : her milk diminished, and its secretion soon ceased. On 
or about the first of August she began to sit up, and on August 11th she 
was admitted into the Sixty-first street branch of the Infant Asylum, pale 
and wasted, but with returning appetite. She had no mammary secretion for 
eleven weeks, and her breasts were small and flabby. She had two fistulous 
openings, one vaginal and the other low down in the back, near the lower end 
of the sacrum or the coccyx. The baby was in a fair condition, having been 
wet-nursed by other women. Experiences in this and other institutions show 
that infants having breast-milk do far better and are much more likely to 
live than those without breast-milk, and the mother was therefore advised by 



SCANTINESS OF MILK. 57 

one of the managers — himself a physician — to suckle her baby, although 
there was not a drop of milk in her breast and nursing had been suspended 
eleven weeks. To the surprise of the mother and of the nurses in the 
house — to whom the procedure seemed very ridiculous — milk began to appear 
in a few days. The mother left the institution October 8th, but before her 
departure she was able to furnish perhaps two-thirds the quantity of milk 
which her infant required. This case affords practical illustration of the fact 
that frequent suckling is the most efficient galactagogue. Mothers sometimes, 
having little breast-milk, suckle their babies at long intervals, and finally, 
discouraged at the unproductive state of their breasts, resort to weaning, 
when by patience and more frequent use of their breasts they might become 
good wet-nurses. In the cities and during the summer season, in which breast- 
milk is so much required, the history of cases like the above, and the more 
remarkable cases in wTiich men and grandparents have had secretion of milk 
and have suckled infants, should induce the physician to withhold his consent 
to premature weaning, which the disheartened mother is apt to suggest, unless 
indeed he perceives other reasons for weaning apart from scantiness of milk. 

Travellers among barbarous nations or tribes have often observed these 
cases of unnatural lactation. Humboldt saw a man thirty-two years old 
who gave the breast to his child for five months, and Captain Franklin in 
the Arctic regions met a similar case. Dr. Livingstone in his African trav- 
els says that he has examined several cases in which a grandchild has been 
suckled by a grandmother, and equally remarkable instances of wet-nursing 
occur among the negroes of the Southern and Middle States. Professor 
Hall presented to his class in Baltimore a male negro, fifty-five years old, 
who wet-nursed all the children of his mistress. In these cases of abnormal 
lactation, so far as we have accurate records of them, it is ascertained that 
the breasts were torpid, and even sometimes, as in old people, atrophied, till 
the nursing commenced. Titillation or pressing of the nipple caused an afflux 
of blood to the gland and developed its functional activity, so that milk was 
produced for the sustenance of the nursling. Therefore, in case of scanty 
secretion of milk the mother may increase the quantity by applying the 
infant often to the breast. If, dissatisfied with the small amount of nutri- 
ment which it receives, it refuse to make the necessary suction, any other 
mode of gentle traction or pressure may be employed in addition. The occa- 
sional employment of another infant or a pup, milking the breast with the 
thumb and fingers, or the gentle suction of a breast-pump, aids in stimulat- 
ing the secretion. Forcible rubbing or traction of the breast defeats the pur- 
pose for which it is employed. It produces too much irritation and tender- 
ness. The best mode of stimulation is by nursing, as it is the natural mode, 
and the effect of the infant at the breast upon the maternal instincts aids in 
promoting the secretion. 

Another mode of increasing the functional activity of the mammary glands 
is by the electrical current. The fact is established by physiological experi- 
ments that glandular organs can be made to secrete more actively by the 
stimulus of electricity, and, accordingly, this agent has been successfully 
employed to promote the secretion of milk. In Routh's Infant Feeding 
several cases are related which show the beneficial effects of this agent 
(page 149 et seq.). Among them are six reported by Dr. Skinner of Liver- 
pool. In all these one or two applications of the electrical current sufficed 
to restore the secretion. The following is Dr. Skinner's mode of employing 
this treatment : 

" 1. Direct. — Both poles must terminate in cylinders, with sponges well 
moistened in tepid water. The positive pole is pressed deep into the axilla, 
while the negative is lightly applied to the nipple and the areola, the current 



58 WEIGHT, GROWTH, LACTATION. 

being no stronger than is agreeable to the patient's feelings. The poles are 
kept in this position for about two minutes. 

" 2. Intramammary . — The poles are to be, as it were, imbedded in the 
mamma and moved about, raising and depressing both poles at once in and 
around the organ for the space of another two minutes. The same is to be 
done to both breasts daily until the secretion is properly established. Hith- 
erto one or two sittings have always sufficed in my hands" (^Communication 
of Dr. Skinner to Dr. Routli). 

In all cases of scanty secretion of milk the regimen of the mother is a mat- 
ter of importance. Personal and domiciliary cleanliness is essential for success- 
ful wet-nursing. A certain amount of exercise in the open air is conducive to 
the health of the mother and to the secretion of abundant and healthy milk. 
A case is related to show the effect of fresh air and out-door exercise on the 
lacteal secretion. A lady of cleanly habits, living in London, had a very 
scanty supply of milk. She removed to the pure air of the seashore, and 
immediately the quantity became abundant and continued so for months. 
Such cases are not infrequent. A mode of life that contributes to the gene- 
ral health of the mother will not fail to augment the quantity of her milk if 
it be scanty, and to improve its quality. 

Much has been written in reference to the diet of women who suckle. It 
is a popular belief that certain articles of food promote the secretion of milk 
much more than other articles, though equally nutritious. No doubt writers 
have erred in recommending exclusively this or that kind of food as most 
likely to produce milk. The exact kind of food which is preferable in a 
certain case depends partly on the physique of the individual and partly on 
the character of the food to which she has been accustomed. A mixed diet 
contributes most to the sustenance of the mother and to an abundant secretion 
of milk. Animal substances which furnish a due supply of nitrogenous ali- 
ment should be given with the farinaceous. Mothers pallid and inclining to 
an anaemic condition require a larger proportion of animal diet than those 
in good general health. On the other hand, plethoric women, such as Routh 
describes, who with excellent appetite consume large quantities of food, and 
who become more and more full-blooded and corpulent while the milk dimin- 
ishes, require a more restricted animal diet in connection with more exercise, 
especially in the open air. 

There are certain kinds of food which do appear to have a galactagogue 
effect with most wet-nurses. Oatmeal gruel is one of these. Wet-nurses 
often remark, after taking a bowl of this, that they feel the flow of milk. Cow's 
milk with some has a similar effect. Porter or ale, taken once or twice a day, 
also promotes the secretion of milk, especially in those who have poor appe- 
tite and whose systems are somewhat reduced. 

A great variety of medicines have been used for their supposed galacta- 
gogue effect. Medicines which improve the general health are no doubt 
sometimes useful for this purpose, such as the vegetable and ferruginous 
tonics and, perhaps, cod-liver oil. But there are other medicines which it is 
claimed have a specific effect on the mammary gland, promoting its secretion. 
Lettuce, wintergreen, fennel, the broom tops (scoparius), and marshmallow 
have been used for this purpose. There can be no doubt that the aromatic 
stimulants, as fennel, anise, and carraway seed, given in soups, sometimes 
stimulate the lacteal secretion. Another medicine which has been recom- 
mended to the profession as a galactagogue is castor oil and the plant from 
which it is derived. 



EXAMIXATIOX OF WET-NUESE. 59 

CHAPTER y. 

SELECTION OF A WET-NUESE. 

In the cities cases are frequent in which mothers, with all possible care 
or endeavor, find themselves unable to suckle their infants. Their health is 
too poor or the milk possesses the properties of colostrum, or it is no longer 
secreted on account of nervous excitement or exhaustion or inflammation of 
the breasts. The number of such cases in the city would surprise physicians 
who are familiar only with the healthy and robust mothers of the country. 
The infant thus deprived of the mother's milk should, if practicable, be fur- 
nished with a wet-nurse. 

The selection of a wet-nurse often devolves upon the physician, and is a 
duty of great responsibility. It is better to select one between the ages of 
twenty and thirty years, and one who has suckled an infant previously. A 
wet-nurse between the ages of twenty and thirty is usually more active, 
cheerful, and conciliatory than one of a more advanced age, and her milk is 
more apt to be abundant and nutritious. Those who have previously suckled 
and had charge of infants are obviously more competent to serve as wet-nurse 
than are primiparge. The milk of a wet-nurse whose infant is under the age 
of six months will ordinarily agree with a new-born infant. If above that 
age it sometimes agrees, but often does not. 

The most difficult and responsible task imposed on the physician in the 
selection of a nurse is to ascertain the exact condition of her health and the 
■quantity and quality of her milk. Constitutional syphilis is common in the 
class of women who present themselves for wet-nursing ; it is often latent or 
its symptoms are easily concealed, and it is communicable by lactation. The 
virus may be received by the infant from fissures or excoriations of the nip- 
ple. The nursling tainted by syphilis may, on the other hand, communicate 
the disease to the nurse through the same source. It is not fully ascertained 
whether the syphilitic virus may be conveyed to the infant by the milk. But 
the cases which have accumulated in the records of medicine are numerous in 
which infants born of healthy parents have contracted syphilis from the 
breasts of diseased nurses (see article Syphilis). These infants have some- 
times led a short and miserable existence, and have occasionally increased the 
misery of the household by imparting the disease to others. The duty is 
therefore imperative on the part of the physician to examine carefully the 
wet-nurse in reference to any evidences of the syphilitic taint. Acquainted 
with the symptoms of syphilis, he may usually, by shrewd questioning and 
hy careful examination of the present appearance and condition of the 
woman, ascertain with considerable certainty whether her system has ever 
heen infected. References should also be obtained and consulted, and, 
if practicable, the physician who has attended her be communicated with. 

It is safer to employ a wet-nurse two months after her confinement than 
previously, for if she have the syphilitic taint it will by this time show itself 
in the innutrition, coryza, and anal sores of her infant. 

There are also, among the women who present themselves for wet-nursing 
in the cities, many of a scrofulous habit and many who possess an hereditary 
tendency to tuberculosis, if indeed they do not already have the incipient 
disease. Such applicants should be rejected on account of the poverty of 
their milk and the probability that they will not be able to endure the debil- 
itating efi"ect of wet-nursing. 

The milk should be examined in order to ascertain its richness and quan- 
tity and whether it contain colostrum. If there be colostrum after the eighth 



60 SELECTION OF A WET-NURSE. 

day, it is probable that there is some fault in the health or digestion of the 
wet-nurse, and that her milk may disagree with the infant. It is not neces- 
sary that the breast should be large in order to furnish a sufficient quantity 
of milk, since, as has been already stated, in some the secretory function is 
active during the time of each nursing, so that, although the breasts are of 
moderate size, a sufficient amount of milk is furnished. The nipples should 
be well formed and prominent, and preference should be given to those wet- 
nurses in whom blood-vessels are seen ramifying over the breasts. 

By examination of the milk its degree of richness can be readily ascer- 
tained. A quantity of it should be placed in a test-tube, and the cream 
which rises to the top indicates, approximately, the character of the milk. 
Good milk furnishes 3 per cent, of cream, and the casein and sugar usually 
correspond in quantity with the cream. An instrument has been invented, 
called the lactometer, by which the exact amount of the cream can be ascer- 
tained. It is simply a tube graded into one hundred divisions. It is placed 
upright and filled with milk, and the number of divisions occupied by the 
cream indicates its proportion in one hundred parts. The lactoscope is 
another instrument employed for the purpose of ascertaining the richness 
of the milk. It consists of two concentric tubes which move upon each 
other. Milk which we wish to examine is poured within the tubes sufficient 
to obscure a light viewed through it three feet distant. The column of milk 
is then diminished till the light begins to be visible. The size of the col- 
umn indicates the degree of opacity and the richness. The lactoscope was 
invented by M. Donne, and is described by him. 

Dr. Minchin recommends a simple mode of determining the richness of 
cow's milk, and it would equally answer for the breast-milk. A vessel hold- 
ing about one ounce, and containing a graduated enamel slab passing diago- 
nally from above downward, is filled with milk. It is then covered with a 
glass slide carried over it in such a way as to exclude bubbles. The number 
of degrees which can be read indicates the character of the milk as regards 
its richness. 

Examination of the milk by the microscope not only enables us to deter- 
mine whether there are abnormal corpuscles or granular elements, but also 
its richness. It should be examined before the cream has separated. Oil- 
globules of small size and few indicate poverty of the milk ; very large oil- 
globules are said to indicate milk which is apt to be indigestible, especially 
in feeble infants. Such are the free globules of the colostrum. Numer- 
ous oil-globules of medium size indicate nutritious milk. In examining the 
milk by the microscope or otherwise in order to determine its richness, the 
important fact should be borne in mind that milk removed from the breast 
at short intervals is richer or more concentrated than that removed at long 
intervals, as we have stated elsewhere. A larger percentage of water is 
present if the interval be four hours than if it be two hours. Another im- 
portant fact which should be borne in mind in testing the milk is that that 
first drawn from the breast is more watery, or not so rich, as that last 
removed or the stripping, as is seen by the following analysis, made by 
Harrington and published by Rotch in his interesting paper on infant 
feeding in the Cyclopde,dia of Diseases of Children : 

Fat. l^^l_ Water. Ash." 

Fore milk 3.88 13.34 86.66 0.85 

Middle milk .... 6.74 15.40 84.60 0.81 

Strippings 8.12 17.13 82.87 0.82 

The increase in the solid constituents of the milk near the close of a 
nursing is said to be chiefly of fat, but partly of the albuminoids. It is 



EXAMIXATIOX OF ]VET-yUESE. 61 

evident, therefore, that the milk obtained from a breast that is emptied at 
short intervals is richer than that obtained when the breast is drawn at long- 
intervals. 

Rotch publishes the following analysis made by Harrington, in which 
this fact is clearly shown : 

Milk drawn at two Milk drawn at twelve 

hours' interval. hours' interval. 

Total solids .... 15.32 10.14 

Water 84.68 89.86 

lUO.OO 100.00 

Yogel in 1850 made the discovery of vibriones in human milk. The 
fact is established that these animalcules may be generated in the milk within 
the breast, though such cases are not frequent. Dr. Gibb describes a case 
which he met (^Rankin//s Abstract, vol. xxxiv.) : An infant seven weeks old, 
wet-nursed by its mother, who had the appearance of perfect health, was, 
nevertheless, ill-nourished and emaciated. It had no diarrhoea or other appa- 
rent disease, and the milk was therefore examined. A^ibriones were dis- 
covered in the milk immediately after it was obtained from the breast. The 
milk had the usual amount of cream, and seemed to the naked eye of good 
quality. According to Dr. Gibb, two genera of microscopic organisms occur 
in the milk — namely, vibriones and monads. It is believed that the monads 
occur in consequence of fermentation of the sugar and the production of 
lactic acid. Vogel also attributed the production of the vibriones to fermen- 
tation occurring in consequence of heat and congestion of the breast connected 
with sexual excitement. This explanation is probably not correct, because 
vibriones sometimes occur when there is no unusual heat of breast and no 
evidence of fermentation. The fact that such organisms may be found in 
milk which seems of good quality to the naked eye affords additional proof 
of the usefulness of the microscope in selection of a wet-nurse. 

Many wet-nurses have a return of the menses as early as the fourth or 
fifth month after delivery. The re-establishment of this function in some 
women impairs the quality of the milk, so as to render it less nutritious, and 
perhaps less digestible, during the time of the catamenial flow, as we have 
stated in a preceding paragraph. In the selection of a wet-nurse, then, pref- 
erence should be given to one who does not have the periodical sickness ; 
but if she be already employed and give satisfaction, the reappearance of 
the catamenia does not indicate the need of the change of nurse, unless the 
digestion of the infant be disordered or its nutrition be impaired. 

In the selection of a wet-nurse attention should also be given to her 
mental and moral traits. Cheerfulness, affection, veracity, and a proper 
appreciation of the responsibility of her situation enhance greatly the value 
of a wet-nurse. Xot less important are habits of temperance and cleanli- 
ness. I could cite cases of the most melancholy results from the absence 
of these traits. In one case idiocy resulted from an infant falling upon the 
pavement from thearms of a reckless or intemperate wet-nurse. 

In most cases the mode of examination indicated above suffices to show 
the character of a wet-nurse, so far as her health and milk are concerned. 
It should be borne in mind, however, that the microscope does not always 
reveal deleterious properties in the milk. Elements which are in a state of 
solution, and are invisible, may occur in excess, so as to impair the quality 
of the milk and render it indigestible. The following case, in which the 
saline ingredients seem to have been in excess, is related by Dr. Hartman 
{British and Foreign Medical Review, vol. xii.") : '-An infant whose mother 
was in good health and had borne several children exhibited a healthy appear- 



62 COURSE OF WET-NURSING— WEANING. 

ance for tlie first five weeks after birth. The alvine evacuations then became 
copious, fluid, and discolored, and the child lost flesh and strength. After 
the usual remedies had been vainly administered for a fortnight, the mother 
remarked that the child did not take the right breast willingly, and so much 
did the unwillingness increase that at length the mere application of the nip- 
ple to the child's lips occasioned loud crying. On examination it was found 
that the milk of the right breast had a distinctly saline taste, whereas the 
milk of the opposite breast was of the ordinary sweetness ; no diff"erence of 
consistence or color was discoverable. From that time the child was only 
allowed to nurse the left breast, and in a few days all diarrhoea and sickliness 
of appearance vanished." In this case there was no appreciable disease of 
the breast, although its secretion was perverted. The deleterious character 
of the milk was discovered, not by any change in its appearance, but by 
the taste. 

It is obviously very necessary, before recommending a wet-nurse, to ascer- 
tain whether she will probably furnish sufiicient milk ; for, however excellent 
she may otherwise be, if she do not satisfy the wants of the infant she obvi- 
ously should not be employed. If the infant of the nurse be well nourished, 
and if it seem satisfied after nursing ten or fifteen minutes, she probably has 
sufiicient milk. The more exact method of weighing the infant before and 
after it nurses, and observing whether the diff"erence corresponds with that 
given in Chapter VII., enables us to determine more accurately the capabil- 
ities of the wet-nurse. 



CHAPTER YI. 

COUESE OF WET-NUKSING— WEANING. 

After the birth of the infant the mother needs rest a few hours — four 
or five or a little longer in tedious and exhaustive cases — and then it should 
be applied to the breast. There is frequently a little milk at this time, and 
the act of nursing promotes the secretion and increases the quantity. The 
full secretion is not, however, established before the third day, and, though 
the infant be applied to the breast often, it obtains but little milk. Infants 
are so constituted that they require but little food until it is naturally pro- 
vided for them, and the common practice of feeding them to repletion with 
various sweetened mixtures almost as soon as life begins, because they obtain 
little breast-milk, is to be deprecated. Filling their stomachs in this way has 
a tendency to prevent their drawing upon the nipples with the avidity which 
is required to stimulate a free flow of milk. Besides, as I have many times 
observed, indigestion, diarrhoea, and sprue are common results of this inju- 
dicious feeding. If, therefore, the infant be applied to the breast every 
second hour when the mother is awake till the third day, and be fed nothing, 
besides, there need be no anxiety as regards its nutrition. If on the third 
day the breasts do not begin to fill and the secretion be delayed, a little fresh 
cow's milk, diluted with double its quantity of warm water, and slightly 
sweetened, should be given every fourth hour, but should be withheld as 
soon as the flow of milk occurs. 

Infants under the age of one month should nurse about every hour and 
a half by day and at longer intervals by night, or about twelve times in 
twenty-four hours, for the stomach of the new-born holds but little, and 



AILMENTS OF NURSING INFANTS. 63 

therefore receives but little at each nursing, and its digestion is active. 
The interval should be longer at night than in the day-time, so as to allow 
the mother more sleep. In the second month the interval should be about 
two hours, and it should be gradually lengthened as the age increases, so that 
after the fourth month nursing should be about every third hour, and after 
the sixth month, when the use of some artificial food is proper, every fourth 
hour. 

The infant should be habituated to nursing at regular intervals, and when 
it is it will ordinarily awaken at about the proper time. The practice on the 
part of the mother of applying the babe to the breast whenever it frets and 
as a means of quieting it, although it have but just nursed, is pernicious 
and should be forbidden. Giving the stomach no time to rest or filling it to 
repletion tends to produce indigestion a«d diarrhoea and to increase its fret- 
fulness. The cause of the fretfulness should be sought for, that the proper 
measures may be applied. In ignorance of the cause it is better to quiet 
restlessness by carrying the child, or even by rocking it, than to increase the 
task of the digestive function. Fretfulness of infants is often due to colic or 
griping produced by irritating products of imperfect digestion in the intes- 
tines, and the addition of more food has a tendency to increase rather than 
to diminish it. 

While regularity in nursing is required, still, as M. Donne has said, 
mathematical exactness in this matter would be ridiculous. Quiet natural 
sleep of a well-nourished infant should not be interrupted in order to give it 
the breast, unless the sleep be unusually protracted. It will usually awaken 
when the system requires more nutriment. Ill-nourished infants often sleep 
but little, making known their want by crying and fretfulness, until they 
become wasted and prostrated, when they are drowsy in consequence of pas- 
sive congestion of the brain. This drowsiness is evidently a pathological 
symptom. It shows the need of increased nutrition. It is due to scantiness 
of milk or milk of poor quality, and the infant should be aroused frequently 
for the purpose of giving it nutriment or even stimulants. The breast-milk 
is sufficient for its nutrition till the age of six or eight months, provided that 
it is abundant and of good quality. Therefore, if the mother be strong and 
experience no exhaustion, no other nutriment need be given till that age. 

Many mothers, however, by the third or fourth month of wet-nursing find 
that they have not sufficient milk to meet the wants of the infant. The con- 
stant drain upon their systems sensibly impairs their health. In such cases 
it is proper to commence with a little feeding from the spoon or bottle, and 
increase the quantity given as the infant grows older. Great care is, how- 
ever, requisite in the preparation of food for so young an infant, whose 
digestive organs are still feeble and easily deranged. In the country, where 
diarrhoeal afiections and the so-called gastric derangements are not frequent, 
the danger from artificial feeding is less than in the city, and in the cool 
months in the city the danger is less than in the summer season. Infants of 
the city between the months of May and October have a strong predisposition 
to diarrhoeal .attacks, the result of antihygienic influences which surround 
them. Errors of diet in their case readily provoke disease or derangement 
of the digestive organs, often of a severe and dangerous form. Moreover, 
experience has shown that artificial feeding during the period when nature 
designed that they should be nourished at the breast very commonly produces 
in the hot months more or less vomiting and diarrhoea, followed by emacia- 
tion and other evidences of malnutrition. Therefore an exception must be 
made in case of the city infant as regards the commencement of artificial 
feeding. If it be under the age of one year, it should be nourished exclu- 
sively, or almost exclusively, at the breast during the hot months when prac- 



64 QUANTITY OF FOOD REQUIRED. 

.ticable, even if the mother suffer somewhat in her health from the constant 
drain upon her system. It should, however, receive the amount of nutriment 
which it requires, and, if there be not sufficient breast-milk, it will be neces- 
sary to supply the deficiency by artificial feeding. The reader is referred to 
Chapter VIII. for facts relating to the subject of artificial feeding. 

Weaning ought to take place, as a rule, between the ages of ten and 
twelve months. It is well, if the mother's health be good and her milk 
sufficient, to defer weaning till the canine teeth appear. The infant, then 
possessing sixteen teeth, is able to masticate the softer kinds of solid food. 
Weaning should be gradual. Mothers often speak of weaning on a certain 
day. They have given but little artificial food and have suckled at regular 
intervals, till at a fixed time they have denied the breast altogether. This 
abrupt change of diet should be discouraged. It should only be recom- 
mended under peculiar circumstances. It is apt to derange the digestive 
organs, and it causes fretfulness and sleeplessness on the part of the infant 
for a week or more. Weaning should commence by feeding with a spoon a 
little oftener through the day, and nursing less, and by discontinuing the 
practice of suckling at night. The infant tolerates this gradual change of 
diet, while it rebels against sudden weaning, and by its fretfulness increases 
greatly the care and trouble of the mother. Nurslings in the city should 
not be weaned in warm weather nor within a month immediately preceding 
it. If the mother's health fail or her milk become deficient in the summer 
months, so that she cannot continue suckling, a wet-nurse should be employed, 
or the infant should be sent to some rural locality and weaned there. Wean- 
ing *in the city in hot weather should, if practicable, be avoided on account 
of the liability to the summer diarrhoea produced by change of diet, although 
I believe there is less danger from this than formerly, since we now under- 
stand better how to feed infants. 



CHAPTER VII. 

QUANTITY OF FOOD EEQUIKED IN INFANCY AND CHILDHOOD. 

Infantile Feeding. 

Over-feeding. — Nearly half a century has elapsed since the most distin- 
guished New England physician of his day. Dr. James Jackson of Boston, 
wrote in his Letters to a Young Physician that a certain ailment of the diges- 
tive system of infants had often puzzled him when a young practitioner. It 
was characterized by the occurrence of green and unhealthy stools, showing 
imperfect digestion. The stools contained an unusual amount of mucus, and 
were passed more frequently than the normal stools of a healthy infant. 
After observing many infants thus affected, and ascertaining the manner and 
frequency of their feeding, the truth gradually dawned upon him that their 
unhealthy evacuations were due to over-feeding. By diminishing the amount 
of nutriment given and lengthening the intervals between the feedings, these 
infants were soon cured. 

Suction by the lips of the infant seems to be to a great extent automatic, 
so that if its mother or wet-nurse have a copious supply of milk, it is liable 
to over-nurse, or, if it be bottle-fed, is liable to take more from the bottle 
than it requires for its nutrition. Some infants if over-fed regurgitate the 



INSUFFICIENT NOURISHMENT. 65 

surplus food, but others do not, and the portion which is not digested under- 
goes fermentation and acts as an irritant to the stomach and intestines. 
Acids, as the butyric and lactic, and gases which distend the stomach and 
intestines and cause colicky pains, form from the fermentation. An infant 
thus suffering from overtaxed digestion, and from the presence of irritating 
acids and gases in the stomach and intestines, is usually fretful and its sleep 
is disturbed and broken. The cause of its restlessness is often misunder- 
stood by the mother, who thinks it may be due to insufficient nutriment, and 
accordingly- it is applied more frequently to the breast, or, if it be bottle-fed, 
it is given the bottle more frequently. I have seen not a few over-fed infants 
who on account of their fretfulness were applied to the breast at intervals of 
a few minutes, so that the health of their mothers was impaired by the lack 
of sleep and the drain upon their systems; and the infants, on account of 
too frequent nursing, suffered indigestion, and occasionally from gastro-intes- 
tinal catarrh. Moreover, milk drawn too frequently from the breast usually 
contains an excess of the solids, so that it is digested with more difficulty 
than when it is drawn at the proper intervals, as I have elsewhere stated. 
For this reason also too frequent application of infants to the breast is likely 
to cause indigestion and gastro-intestinal derangements. 

Cases might be related to substantiate these statements. Thus in Decem- 
ber last I attended an infant of four months that had been very fretful and 
with insufficient sleep for weeks. The wet-nurse who had charge of it had 
apparently the proper requisites, such as health, youth, robustness, and well- 
developed breasts, which seemed to furnish sufficient milk and of good qual- 
ity. But the infant, though fairly nourished, had so little sleep and was so 
fretful, crying so much during the night as well as day, that the whole house- 
hold was deprived of the needed rest. The nature of the baby's ailment 
was soon detected, for its stools presented appearances indicative of indiges- 
tion and intestinal catarrh. They contained numerous rounded, whitish 
masses, apparentl}^ of casein mixed with mucus and thin fecal matter. 
Pepsin preparations with bismuth were at first employed, without any 
marked result, but improvement began at once when the infant, instead of 
being frequently applied to the breast, as had been the practice, was allowed 
to take it only every third hour, and was fed nothing in the interval. It had 
been over-fed, and the remedy more effectual than the medicines employed 
was the simple one of its less frequent application to the breast. Over-feed- 
ing is, I think, more common with bottle-fed infants than with those nour- 
ished at the breast. 

Insufl&cient Nutriment. — On the other hand, infants, both wet-nursed 
and bottle-fed, frequently do not obtain sufficient nutriment. In families of 
the city poor nursing mothers often have scanty diet and are overworked, and 
the milk which they furnish to their nurslings under such circumstances is 
liable to be watery and insufficient. Sometimes infants, when they have 
reached an age at which the breast-milk is inadequate and additional food 
is urgently needed, are nevertheless denied this by their mothers. Even 
mothers who are apparently robust and give the breast at proper intervals, 
often have insufficient milk, so that their infants do not thrive, and they are 
ignorant of the cause. MM. Yernois and Becquerel, on careful examination 
of 89 infants wet-nursed by women apparently in good health, ascertained 
that 15 were insufficiently nourished. An infant that obtains sufficient breast- 
milk draws the breast quietly and continuously twelve or fifteen minutes, 
when it releases its hold of the nipple and probably falls into a quiet sleep, 
having a satisfied aspect. If the breast-milk is scanty and insufficient, the 
baby is fretful when it nurses, frequently lets go of the nipple, and does not 
have the quiet sleep of the satisfied infant. If its mouth be inspected when 



6Q QUANTITY OF FOOD REQUIRED. 

it is nursing, it will be found to contain but little milk. But if the supply 
of breast-milk be abundant, it will appear in quantity between the lips and 
in the mouth of the infant during the nursing. 

Again, many bottle-fed infants are allowed sufficient food, but it is not 
adapted to their age, and is digested with difficulty, so that the nutriment 
which they derive from it is insufficient. Much has been said and written 
upon the practice common in tenement-houses of giving farinaceous food to 
infants under the age of three months, when the saliva, which is the chief 
agent that digests starch, is scanty and insufficient for its digestion. In the 
feeding of older children in families of the laboring class we know how fre- 
quently food is employed that is unsuitable to the age — that acts as an irri- 
tant to the stomach and intestines, producing attacks of vomiting and diar- 
rhoea. The portion of such food that is digested and which serves for 
nutrition is insufficient, while the undigested part acts as an irritant. Infants 
that receive such unsuitable diet really suffer from lack of food, although its 
bulk may be sufficient. They are hungry from the lack of proper nutri- 
ment, and are consequently fretful. They digest and assimilate so small a 
part of this unsuitable diet that they lose flesh and have the usual symptoms 
of innutrition. 

It is evident from this survey of what actually occurs in the feeding of 
infants that while it is of the utmost importance that food should be of the 
proper kind according to the age and properly prepared, it is also equally 
necessary for their successful alimentation that they be fed at proper inter- 
vals and with the proper amount of food. Certain physicians, appreciating 
the importance of a correct knowledge of the amount of food required by 
infants, have made careful observations in order to ascertain it. M. Parrot 
(L' Afhropsie, Paris, 1877) weighed infants before and after each feeding 
with cow's milk. The number of feedings was six in twenty-four hours. 
His observations were scarcely sufficient in number for accurate deductions, 
but he concluded from them that the quantity of cow's milk required in 
twenty-four hours is as follows : 9 J ounces for the first month, 19 ounces for 
the second, third, fourth, and fifth months, and 25 ounces for the sixth month. 
This estimate is for pure cow's milk, used without dilution. The use of 
milk in its pure state and undiluted he considers preferable to that of diluted 
milk. After the sixth month he thinks that 4^^ to 6| ounces for each month 
should be added to the quantity previously employed. Meigs and Pepper 
mention the case of an infant of four months that took 36 ounces of 
breast-milk daily, and another of five to six weeks that took 18 to 23 
ounces. The same authors cite the observations of M. Bouchard, who 
concludes, from weighing infants, that while the newly-born require much 
less breast-milk than those who are older, 20 ounces daily are needed 
between the ages of one and three months, 23 ounces after the third 
month, 27 ounces after the fourth month, and 30 ounces between the ages 
of six and nine months. 

Dr. Ssnitkin of St. Petersburg some time since prepared a formula for 
determining the quantity of food required by young infants which he believes 
is a safe and reliable guide. In his opinion the greater the weight of the 
infant the greater is the capacity of its stomach and the greater is the amount 
of food required. If this rule be invariably true, or true in a large majority 
of instances, the difficult problem of determining how much to feed infants 
each time or each day would have a comparatively easy solution, for by 
weighing the infant we could readily determine how much food it requires. 
Since the formula devised for infant-feeding by Dr. Seibert, and presented to 
the consideration of the profession in this country, is also based upon differ- 



INSUFFICIENT NOURISHMENT. 67 

ences in the weight of infants, and not upon differences in their ages, I will 
briefly relate facts which in my opinion show the impropriety and incorrect- 
ness of this method. Is it a fact that the heaviest animals of a species uni- 
formly require the most food? Is not the amount of food required deter- 
mined to a considerable extent by the activity of the animal and the amount 
of molecular disintegration consequent on exercise ? Take two infants of 
the same age. One may lead a sluggish life, being most of the time asleep. 
It has a superabundance of fat and weighs heavily. The other is more hours 
awake and its limbs are more active. It probably weighs one or two pounds 
less than the other infant, as it has less fat and more frequent evacuations. 
Does not the latter infant require as much food as the former? A rachitic 
child with big head and joints and pendulous abdomen may weigh a pound 
more than a healthy child of the same age. Does he in consequence require 
more food ? A large proportion of the infants remaining in the city during 
the summer months either lose or do not gain in weight. They weigh no more, 
and often less, at the close of September than at the beginning of June. 
Shall we give them the same amount of food, or even less, at the end of 
September, when their appetite begins to return, than they were allowed on 
the first of June, because they weigh the same or less ? Infants that have 
had any sickness except the mildest lose in weight : must we diminish the 
quantity of their food so that it will correspond with the loss of weight? 
In the New York tenement-houses a large proportion of the infants, even 
those without any marked ailment, weigh less than they should on account 
of their improper feeding. Must we under such circumstances give them at 
each feeding an amount of food corresponding with their weight? Let me 
illustrate by a case. A physician in large practice requested me to examine 
an infant that was puny and delicate and had ceased growing. It probably 
did not have more than three-fourths of the ordinar}' weight of infants of 
the same age. When the question was asked how the infant was fed, the 
physician replied before the family, with an air of assurance, that he had 
given explicit directions that the baby should be fed with one teaspoonful of 
condensed milk to a gobletful of water ; and this had been the diet for a 
considerable time. It had abundant urination with uniformly constipated 
bowels. I am sure that neither Dr. Ssnitkin nor Dr. Seibert, had he been in 
my place, would have put this diminutive and ill-used infant in the scales 
in order to determine how much food to give it. I cite these instances not 
to throw discredit on the praiseworthy investigations of Drs. Ssnitkin and 
Seibert, but in order that I may ask them if in formulating rules for the 
feeding of infants it is not necessary to regard other circumstances besides 
the weight, especially the age. We know that improvements in the care and 
treatment of children, especially such improvements as require mechanical 
appliances, are seldom perfected at once, but after many changes which 
experience suggests. Witness, for example, intubation. Many observations 
by different observers and under different circumstances are required, in my 
opinion, in order to obtain the data for formulating rules for the feeding of 
infants which will require no change. 

A few years since Drs. Chadbourne, Parker, and myself made ob!5erva- 
tions in the New York Infant Asylum and New York Foundling Asylum in 
order to determine how much food children require at different ages. Those 
selected for observation were well nourished, and they were accurately weighed 
before and after each nursing or feeding. Eleven infants under the age of 
three weeks, who took the breast, with three exceptions, twelve times in the 
twenty -four hours, were found to take in the average 12.55 ounces of the 
breast-milk in the day and night, as is seen by the following table : 



68 



QUANTITY OF FOOD REQUIRED. 



Table I.- 


-Newly-horn 


Infants (those w 


der the Age of Three 


Weeks). 










MiUc nursed 


in 24 hours. 


No. 


Name. 


Age. 


Number of 
nursings. 


Quantity in 


Quantity in 












weight. 


fluidouuces. 












oz. dr. 




1 


J. F 


17 davs. 


11 


10 i 


9.75 


2 


H. a . 
















16 




9 


13 5 


13.24 


3 


H. J. . 
















19 




9 


10 3 


10.07 


4 


R. . . . 
















5 




12 


22 7 


22.22 


5 


H. B. . 














. i 6 




12 


15 5^ 


15.25 


6 


W. F. 














. ! o 




12 


10 li 


9.88 


7 


K H. . 














• ! 14 




12 


17 3 


16.85 


8 


C. F. . 














5 




12 


5 4 


5.37 


9 


F.D. . 














7 




12 


14 4 


14.8 


10 


E. S. . . 














6 " 


12 


8 1 


7.74 


11 


R. B. . 








• ■ j 3 weeks. 


12 


14 1 


13.68 



According to these statistics, infants under the age of three weeks nour- 
ished at the breast and suckled twelve times in the twenty-four hours require 
only one ounce, or not more than one ounce and a drachm, at each nursing; 
and the very small size of the stomach at this age shows, I think, that it 
cannot receive much more than this without distension. After the third 
week the amount required for healthy nutrition gradually increases. 





Table I] 




—Ages from One Month to Ten Months. 












Milk nursed 


in 24 hours. 


No. 


Name. 


Age. 


Number of 
nursiugs. 


Quantity in 
weight. 


Qu.tntity ia 
fluidouuces. 










oz. dr. 




1 


A.S. 


6 months. 


8 


26 U 


25.3 


2 


J. B 








4 " 


9 


38 \ 


36.8 


3 


W. G. . . 










^ " 


8 


24 2 


23.5 


■4 


L.B. . . 












7 '' 


10 


27 3^ 


26.6 


5 


W. L. . . 












5i " 


11 


28 7 


28 


6 


J. C. . . . 












5 " 


10 


29 7 


29 


7 


A. W. . . 












3^ " 


8 


19 2 


18.6 


8 


F. Van B. 












2m.l0d. 


7 


24 4 


23.7 


9 


E. W. . 












6 months. 


10 


12 4J 


12.2 


10 


F. S. . . 












33. " 


8 


26 7 


26.1 


11 


S.W. . . 












4 '^ 


8 


23 5 


22.9 


12 


J. G. . 












9 


8 


24 1^ 


23.4 


13 


B.J. . . 












1 ' 


8 


27 4 


26.6 


14 


T. C. . . 












6 " 


10 


26 6^ 


26 


15 


A. K. . 












6 " 


10 


21 6 


21.1 


16 


C. H. . . 












1 m. 5 d. 


8 


11 U 


10.84 



The observations in the second table relate to infants between the ages 
of one month and ten months, and, with one exception, between the ages of 
two months and ten months. It was found that they received in the average 
23.79 fluidounces of breast-milk in twenty-four hours. The number of 
nursings in the day and night varied from seven to ten. Therefore those 
infants between the ages of one — or, more accurately, two — months and ten 
months, if they took the breast eight times in the twenty-four hours, required 
three ounces at each nursing ; if twelve times, they required two ounces 
each time. 

The following observations were made by me in private practice. All 
the infants were well nourished, having the symptoms of normal, hearty 



NUMBER OF DAILY FEEDINGS. 



69 



digestion. An infant at the age of six weeks took six times in twenty-four 
hours one and a half ounces of milk, the same quantit}'^ of water, and one 
teaspoonful of barley flour with the starch converted into maltose by the 
action of malt (Liebig's method) ; an infant of eight weeks, of large size, 
took eight times daily two ounces of milk, two of water, and two scant tea- 
spoonfuls of Liebig's flour ; an infant of two months took eight times daily 
one teaspoonful of Liebig's flour, with three and a half of milk and three 
and a half of water ; an infant of six months took at each feeding, and nine 
times in twenty-four hours, five tablespoonfuls of milk peptonized by Fair- 
child's process, with four of water. 

According to my observations, infants in good health and well nourished 
do not all require or take the same amount of food. Some infants, like 
adults, need more food than others, but the following table indicates, 1 think, 
nearly the quantity required during the first twelve months of infancy, either 
of breast-milk or of food prepared so as to resemble as closely as possible 
breast-milk in consistence and nutritive properties. It will be observed that 
this table resembles closely that prepared by Professor Rotch of Harvard 
University, and published in his comprehensive and instructive paper on 
infant feeding in the Cyclopaedia of the Diseases <>f Children : 



Table lll.— Quantiti/ of Food 


requi) 


'ed in 


the First Year of 


Infancy. 


At each 


feeding. 








Number of 
daily feedings. 


Total 
daily quantity. 


During the first week 1 oz 


10 
10 
8 
8 
7 
6 
5 


10 oz. 


At the third week \h oz 


15 " 


At the sixth week 2 oz . ... 


16 " 


At the third month 3 oz 


24 " 


At the fourth month 4 oz 


28 " 


At the sixth month 6 oz ■ 


36 " 


At the tenth to twelfth mon 


ths 8 oz. . 








40 " 



Table IV. — Observations relating to the Diet during Twenty four Hours of 
Twenty-eight Healthy Children between the Ages of Two and Three Years, 
with an Average Age of Two Years and Eight Months. 



Bread . . 


Breakfast. 


Butter 


Milk 


Meat . . . 


Dinner. 


Potatoes 

Milk 


Milk . . . 


Supper. 


Bread 


Butter . . 





Total amount. 


Average for each. 


6 lbs. 4 oz. 1 dr. 


3.5 oz. 


13 oz. 5 dr.i 


0.45 oz. 


22 lbs. 14 oz. 2 dr. 


12.7 fl. oz. 


8 lbs. oz. 5 dr. 


4.6 oz. 


6 lbs. 13 oz. 7 dr. 


3.9 oz. 


17 lbs. 9oz. 7dr. 


9.4 fl. oz. 


19 lbs. 12 oz. 1 dr. 


10.5 fl. oz. 


7 lbs. 1 oz. 2 dr. 


4.0 oz. 


14 oz. 7 dr. 


0.53 oz. 



DAILY AVERAGE FOR EACH CHILD. 

Bread 7.5 oz. avoir. 

Butter •. 98 oz. " 

Meat (beef) 4.6 oz. " 

Potatoes 3.9 oz. " 

Milk 32.6 fl. oz. 

^ 354.6 fluidounces. 



70 



QUANTITY OF FOOD REQUIRED. 



Table V. — Observations upon Twelve Children between the Ages of Three and 
Six Years : Average Age, Four Years and Ten Months. 



Bread . . 


Bkeakfast. 


Butter ... 


Milk 


Beef . 


Dinner. 


Bread 


Eice 


Milk 


Butter 


Bread . . 


Supper. 


Butter 

Milk 



Total amount. 


Average for each. 


4 lbs. 6oz. 3Jdr. 
5 oz. 2 dr. 

280 fl. oz. 


• 

5.86 oz. 

0.427 oz. 

23.3 fl. oz. 


9 lbs. 1 oz. 3 dr. 
1 lb. oz. 1 dr. 
9 1bs. 12oz. 7 dr. 
112 fl. oz. 

2 oz. 2J dr. 


12.1 oz. 

1.6 oz. 
13.0 oz. 

9.3 fl. oz. 


2 lbs. 4 oz. 1 J dr. 
5 oz. 5i dr. 
192 fl. oz. 


3.0 oz. 
16.0 fl. oz. 



DAILY AVERAGE FOR EACH CHILD. 

Milk 48.6 fl. oz. 

Beef 12.1 oz. avoir. 

Rice 13.0 oz. " 

Bread 10.3 oz. " 

Butter 1.08 oz. " 



Table VI. — Observations relating to the Diet of Tweytty-four Children — Twelve 
Boys^ Twelve Girls— between the Ages of Four Years and Ten Years: 
Average^ Six Years and Ten Months. 





Total amount. 


Average for each. 


Breakfast. 

Bread 

Butter ... . 


7 lbs. 13 oz. 3 dr. 
12 oz. 3Jdr- 
348 fl. oz. 

IS lbs. 11 oz. dr. 
15 lbs. 8 oz. 3 dr. 
1 lb. 6 oz. ■ ^ dr. 
192 fl. oz. 

6 lbs. 2 oz. 3| dr. 
384 fl. oz. 

11 oz. 5 J dr. 


5.21 oz. 
0.51 oz. 


Milk .... 


14.5 fl. oz. 


Dinner. 
Boast beef . . . 


12.46 oz. 


Potatoes . 

Bread 

Milk 


10.30 oz. 
0.92 oz. 
8.0 fl. oz. 


Butter 


0.012 oz. 


Supper. 

Bread . 

Milk 

Butter . ... 


4.1 oz. 

16.0 fl. oz. 

0.16 oz. 







DAILY average FOR EACH CHILD. 

Eoast beef 12.46 oz. 

Bread 10.23 oz. " 

Potatoes 10.3 oz. 

Butter . . . , 0.99 oz. 

Milk 38.5 fl. oz. 

Compare the above observations witli those of Professor Dalton, who 
estimates that a healthy adult taking active exercise requires each day — 



TIME REQUIRED FOR DIGESTIOy. 71 

Meat 16 oz. 

Bread 19 oz. 

Butter 3| oz. 

Water 52 oz., 

while one leading a sedentary life needs considerably less. 

It will be seen by the above tables that even more food appears to be 
needed during the period of childhood than in adult life. We would suppose 
this to be so without statistical evidence, for the active exercise and rapid and 
progressive growth of this period necessarily require a large amount of nutri- 
ment. Moreover, while adults do well with solid food and water, statistics 
show that the best diet for children who have passed beyond infancy is one 
of milk, with solid food for at least breakfast and supper. 

Although we are able, by observations, to determine the average amount 
of food required in twenty-four hours by children of various ages, we repeat 
that it would be wrong to prescribe a fixed amount for all children of a given 
age, for some need more than others. A child should never go hungry after 
a meal. In some of the best-conducted institutions of New York the chil- 
dren eat of plain food all that they desire at each meal, while in other insti- 
tutions the food at supper is limited, but is abundant at the other meals. As 
children go to bed so soon after supper, it is proper to have this meal light 
and of such food as is easily digested. 

The time required in the digestion of different foods has been investigated 
by Beaumont and Bichat, but their investigations relate to adults. The time 
occupied in the gastric digestion of various foods has been determined in 
adult cases by inspecting the interior of the stomach through a gastric fistula. 
No such opportunity has ever occurred, so far as I am aware, of inspecting 
the process of digestion in the interior of the stomach either in infancy or 
childhood. But recently experiments have been made for the purpose of 
determining the time occupied in gastric digestion in infanc}^ The import- 
ance of such experiments is apparent, for if we know how soon after feeding 
gastric digestion is completed and the stomach emptied, we will know how fre- 
quent the feeding should be. According to H. Leo, in an infant a few weeks 
old one hour suf&ces for the stomach digestion of the milk which it receives, 
so that this organ is already empty one hour after the nursing, and in a con- 
dition to receive more milk. In older infants, who receive more milk, the 
milk is retained longer in this organ, one and a half hours being required for 
the stomach digestion of human milk, and two hours for the digestion of 
cow's milk {Berlin. Mux. Wochenschr., No. 49, 1888). Kecently (1889), Dr. 
Max Einhorn of New York has investigated the stomach digestion of infants, 
using a Nelaton catheter No. 14 A, with which he withdrew the contents or 
determined the emptiness of the stomach. He ascertained that in the infant 
receiving human milk the stomach was empty two hours after the nursing, 
and probably in one and a half hours. After feeding with equal parts of 
cow's milk and barley-water, the stomach was practically empty at a little 
before the close of the second hour. After feeding with milk and water, 
equal parts, the stomach was empty in about one and a half hours. The 
digestibility of several of the proprietary foods which are most in use was 
also ascertained in a similar manner. A considerable amount of these foods 
was still in the stomach undergoing digestion two hours after they were 
administered. These interesting and instructive observations of Dr. Einhorn 
indicate the intervals required in feeding with milk and with other foods. 

It is seen that there is a general agreement in the result obtained by dif- 
ferent observers in regard to the amount of food required at each feeding. 
and the proper intervals between the feedings, during infancy as well as 
childhood. 



72 



ARTIFICIAL FEEDING. 



CHAPTER VIII. 



ARTIFICIAL FEEDING. 



Occasionally the mother is unable to suckle her infant, and a hired wet- 
nurse cannot be or is not obtained. Artificial feeding is then necessar3^ In 
the large cities this mode of alimentation for young infants should always be 
discouraged, for it frequently ends in death, preceded by evidences of faulty 
nutrition. A considerable proportion of those nourished in this manner thrive 
during the cold months, but on the approach of the warm season they are the 
first to be aff"ected with diarrhoea and other symptoms indicating derangement 
of the digestive function. In New York City a large proportion of the arti- 
ficially-fed infants who enter the summer months die before the return of cool 
weather, unless saved by removal to the country, but the mortality of these 
infants has been in a measure reduced of late years by improvement in the 
mode of feeding, and in the sanitary condition of the city. In the country 
and in small inland cities the results of artificial feeding are much more favor- 
able. In elevated farming sections, on account of the salubrity of the air 
and the facility with which milk, fresh and of the best quality, is obtained, 
artificial feeding is attended by much less risk than in the cities. 

Young infants, fed by the hand, obviously require food prepared so as to 
resemble as closely as possible human milk in its composition. Woman's 
milk in health is always alkaline. It has a specific gravity of 1031.7 ; cow's 
milk has a specific gravity of 1029. That of cows stabled and fed upon other 
fodder than hay or grass is decidedly acid. That from cows in the country 
with good pasturage is also slightly acid. In two dairies in Central New 
York a hundred miles apart, in midsummer, with an abundant pasturage, two 
competent persons whom I requested to make the examinations found the 
milk moderately acid immediately after the milking in all the cows. 

How to feed infants deprived of breast-milk is a very important problem. 
The following results of a large number of analyses of woman's and cow's 
milk, made by Konig and quoted by Leeds, and of several of the best-known 
and most used preparations designed by their inventors to be substitutes for 
human milk, show how far these substitutes resemble the natural aliment in 
their chemical characters : 





Woman's milk 


. 




Cow'.s milk. 






Mean. 


Minimum. 


Maximum. 


Mean. 


Minimum. 


Maximum. 


Water 


87.09 


83.6 


90.90 


87.41 


80.32 


91.50 


Total solids .... 


12.91 


9.10 


16.31 


12.59 


8.50 


19.68 


Fat 


3.90 


1.71 


7.60 


3.66 


1.15 


7.09 


Milk-sugar .... 


6.04 


4.11 


7.80 


4.92 


320 


5.67 


Casein 


0.63 


0.18 


1.90 


3.01 


1.17 


7.40 


Albumen .... 


1.31 


0..39 


2.35 


0.75 


0.21 


5.04 


Albuminoids . . . 


1.94 


0.57 


4.25 


3.76 


1.38 


12.44 


Ash 


0.49 


0.14 


. 


0.70 


0.50 


0.87 



The following analyses of the foods for infants found in the shops, and 
which are in common use, were made by Leeds of the Stevens Institute : 



ARTIFICIAL FOODS. 



73 



Farinaceous Floods. 



Water 

Fat 

Gra[je-sugar 

Cane-sugar . . . . 

Starch 

Soluble carbohydrates 
Albuminoids . . . . 
Gum, cellulose, etc. . 
Ash 



1. 

Blair's 
wheut 
food. 



9.85 
1.56 
1.75 
1.71 
64.80 
13.69 
7.16 
2.94 
1.06 



Hubbell's 
wheat food. 



Imperial 
o;iauiim. 



7.78 

0.41 

7.56 

4.87 
67.60 
14.29 
10.13 

Undeterm'd 
1.00 



5.49 
1.01 

Trace. 

Trace. 

78.93 
3.56 

10.51 
0.50 
1.16 



Ridge's 
food. 



9.23 
0.63 
2.40 
2.20 
77.96 
5.19 
9.24 

0.60 " 



"ABC" 
Cereal milk. 



9.33 

1.01 

4.60 

15.40 

58.42 

20.00 

11.08 

1.16 



6. 

Robinson": 

patent 

barley. 



10.10 
0.97 
3.08 
0.90 

77.76 
4.11 
5.13 
1.93 
1.93 







Liehig' 


s Foods. 










Mellin's. 


Hawley's. 


j Keasbey 
Horlick's. j^^^^. 
sou's. 


Savory 

and 
Moore's. 


Baby snp 
^'o. 1. 


Baby 

sup 

No. 2. 


Water 

Fat 

Grape-sugar .... 

Cane-sugar 

Starch 

Soluble carbohydrates . 

Albuminoids 

Gum, cellulose, etc. . . 
Ash 


5.00 

0.15 

44.69 

3.51 

None. 

85.44 

5.95 

" 1.89 


6.60 

0.61 
40.57 

3.44 
10.97 
76.54 

5.38 

1.50 


3.39 27.95 
0.08 \ None. 
34.99 i 36.75 
12.45 1 7.58 
None, j None. 
87.20 1 71.50 
6.71 i None. 

1.28 1 0.93 


8.34 

0.40 

20.41 

9.08 

36.36 

44.83 

9.63 

0.44 

0.89 


5.54 

1.28 

2.20 
11.70 
61.99 
14.35 

9.75 

7.09 

UndetermVl 


11.48 
0.62 
2.44 
2.48 
51.95 
22.79 
7.92 
5.24 
1.59 





Milk Foods. . 








Nestle's. 


Anglo-Swiss. 


Gerber's. 


American-Swiss. 


Water 


4.72 


6.54 


6.78 


5.68 


Fat 


1.91 


2.72 


2.21 


6.81 


Grape-sugar and milk-sugar . . . 


6.92 


23.29 


6.06 


5.78 


Cane-sugar . 


32.93 


21.40 


30.50 


36.43 


Starch 


40.10 


34.55 


38.48 


30.85 


Soluble carbohydrates 


44.88 


46.43 


44.76 


45.35 


Albuminoids 


8.23 


10.26 


9.56 


10.54 


Ash 


1.59 


1.20 


1.21 


1.21 



It is seen by examination of the analyses of the above foods that all, 
except such as consist largely or wholly of cow's milk, differ widely from 
human milk in their composition, and although some of them — as the Liebig 
preparations, in which starch is converted into grape-sugar by the action of the 
diastase of malt — may aid in the nutrition and be useful as adjuncts to milk, 
physicians of experience and close observation agree that when breast-milk 
fails or is insufficient our main reliance for the successful nutrition of the 
infant must be on animal milk. 

Cow's milk, being readily obtained, is commonly used as a substitute for 
human milk, compared with which it contains less sugar, but more casein and 
salts. Its composition, however, varies considerably, according to the food 
of the cow. The variations in the milk of the cow according to the nature 
of its food and other circumstances have been considered in a preceding 
chapter. 



74 ARTIFICIAL FEEDING. 

It is obvious from the above facts that the analyses of different specimens 
of cow's milk must differ greatly, and the same is true of the milk of the goat 
and ass, and probably of the ewe. In fact, different samples of the milk of 
the same animal may differ more from each other in their chemical character 
than the average milk of one animal from that of another. 

The milk of the goat and that of the ass have been recommended as food 
for infants in preference to cow's milk, on the ground that they more nearly 
resemble human milk. But neither the milk of the ass nor goat, so far as its 
chemical character is concerned, would seem to possess any marked advantage 
over cow's milk. The ass's milk is procured with difficulty, and is seldom 
used. An objection to goat's milk is the unpleasant odor which it often pos- 
sesses, due to the presence of hircic acid. It is stated, however, by Parmen- 
tier, that this odor is only noticed in the milk of goats that have horns. An 
important advantage in the city in the use of goat's milk is that the animal 
can be kept at little expense, so that even poor families who are not able to 
purchase and feed a cow can generally possess a goat from which fresh milk 
can be obtained at any time. Preference is to be given to goat's milk when 
fresh over cow's milk brought from the country, perhaps watered on the way, 
several hours old when received, and in commencing fermentation. But 
cow's milk of good quality and free from fermentative changes is probably 
not inferior to goat's milk as a food for infants, and from its abundance it 
must continue to be in common use for this purpose. 

In order to solve the problem of the feeding of infants deprived of the 
breast milk, it will be well to recall to mind the part performed in the diges- 
tive function by the different secretions which digest food. 

1st. The saliva is alkaline in health. It converts starch into grape-sugar. 
It has no effect upon fat or the protein group. It is the secretion of the 
parotid, submaxillary, and sublingual glands, which in infants under the age 
of three months are very small, almost rudimentary. The power to convert 
starch into sugar possessed by saliva is due to a ferment which it contains 
called ptyalin. 

2d. The gastric juice is a thin, nearly transparent, and colorless fluid, acid 
from the presence of a little hydrochloric acid. It produces no change in 
starch, grape-sugar, or the fats, except that it dissolves the covering of the 
fat-cells. Its function is to convert the proteids into peptone, which is 
effected by its active principle, termed pepsin. 

3d. The bile is alkaline, and it neutralizes the acid product of gastric 
digestion. It has no effect on the proteids. It forms soaps with the fatty 
acids, and has a slight emulsifying action on fat. The soaps are said to pro- 
mote the emulsion of fat. Their emulsifying power is believed to be increased 
by admixture with the pancreatic secretion. Moreover, the absorption of oil 
is facilitated by the presence of bile upon the surface through which it passes. 

4th. The pancreatic juice appears to have the function of digesting what- 
ever alimentary substance has escaped digestion by the saliva, gastric juice, 
and bile. It is a clear, viscid liquid of alkaline reaction. It rapidly changes 
starch into grape-sugar. It converts proteids into peptones and emulsifies fats. 
While the gastric juice requires an acid medium for the performance of its 
digestive function, the pancreatic juice requires one that is alkaline. These 
important facts should be borne in mind, that such a mistake as prescribing 
pepsin with chalk mixture or the extractum pancreatis with dilute muriatic 
acid may be avoided. 

5th. The intestinal secretions are mainly from the crypts of Lieberkiihn, 
and their action in the digestive process is probably comparatively unimport- 
ant, but in some animals they have been found to digest starch. It will be 
observed that of all these secretions that which digests the largest number 



PEPTONIZED MILK. 75 

of nutritive principles is the pancreatic. It digests all those which are 
essential to the maintenance of life except fat, and it aids the bile in emul- 
sifying fat. 

It is seen from this brief review of the action of the digestive ferments 
that starch is digested in only a very small quantity by infants under the 
age of three months, and therefore that those foods which consist largely of 
starch afford but little nutriment at this age. The impropriety also of admin- 
istering for days large quantities of an alkali, as is frequently done, is apparent 
from the above statement in regard to the action of pepsin, since it may retard 
or prevent gastric digestion. 

In 1882 a conference was held in Salzburg, Germany, of physicians from 
various parts of the Grerman Empire known throughout the world as special- 
ists in the diseases of children. The purpose of the convention was to dis- 
cuss the diet of infancy and childhood. They agreed that animal milk is 
the best substitute for human milk in the feeding of infants, either as the 
main food or as the basis of the food employed. Useful as some of the prep- 
arations of the shops are as adjuvants, nevertheless experience shows the 
soundness of the opinion expressed by the conference ; and yet feeding with 
animal milk of the best quality must be carefully managed, or it will be 
found to disagree with the feeble and readily disturbed digestive functions 
of the infant. 

Milk should always be given at a uniform temperature of about 99°. Em- 
ployed habitually too hot or too cold, it frequently produces stomatitis or a 
more serious disease of the digestive organs. 

Infants under the age of ten months should nurse from the nursing-bot- 
tle, and this as soon as used should, with the India-rubber tip and attach- 
ment, be immersed in a quart or two-quart bowl of cold water to which a 
teaspoonfal of sodium bicarbonate has been added, and water should be 
drawn through the tube and nipple by suction with the mouth. 

Cow's milk, though possessing nearly the same composition as human 
milk, nevertheless behaves differently in some respects in digestion. The 
casein of human milk coagulates in light flocculi in the stomach of the 
infant, so as to be readily acted on by the digestive ferments, while that of 
cow's milk forms large and firm coagula which are with difficulty digested. 
The irritating products of a slow and imperfect digestion frequently cause 
colic and fever, with more or less intestinal catarrh. Cow's milk, therefore, 
disagrees with many infants, who suffer from indigestion in consequence of the 
feeding, whose stools show masses of partly-digested casein, with abundant 
mucus, who fret from gastro-intestinal uneasiness and vomit often, and do not 
thrive like infants nourished at the breast. Therefore, the profession has 
long felt the need of some modification of cow's milk, so that it more closely 
resembles. human milk in its digestion. This has in a measure been accom- 
plished by the process known as peptonizing, by which the casein is digested 
or so far digested that it coagulates in flakes. Peptonized milk, or milk which 
is partially digested by artificial means, is prepared by the action upon it of 
extractum pancreatrs and sodium bicarbonate. We may here briefly state 
the method, l^xtractum pancreatis gr. v and sodium bicarbonate gr. xv are 
added to one gill of tepid water, and this is mixed with one pint of tepid milk 
as fresh as possible. The mixture is allowed to stand in water having a tem- 
perature of about 100° to 110° for half an hour, or even one hour if it do 
not become bitter. After the half hour the milk should be frequently tasted, 
and if it be in the least bitter it should be immediately removed from the 
heat, and what is not used should be placed upon ice. If it be fully digested, 
it is too bitter for use. If it be slightly digested, the bitterness is not appre- 
ciable, or is so slight that it is readily taken by the infant, and the casein 



76 ARTIFICIAL FEEDING, 

coagulates in flakes instead of large coagula. Professor Leeds recommends 
the following method as an improvement. In his opinion it produces milk 
so closely resembling breast-milk in its chemical character and behavior that 
he designates it humanized cow's milk : 

1 gill of cow's milk. 

1 gill of water. 

2 tablespoonfuls of rich cream. ' 
200 grains of milk-sugar. 

1\ grains of extractuni pancreatis. 
4 grains of sodium bicarbonate, 

" Put this in a nursing-bottle, place the bottle in water made so warm 
that the whole hand cannot be held in it without causing pain longer than 
one minute. Keep the milk at this temperature for exactly twenty minutes. 
The milk should be prepared just before using." Messrs. Eairchild have pre- 
pared according to the above formula what they designate a peptogenic pow- 
der in a can accompanied by a measure which holds sufficient for peptonizing 
two ounces of milk with half an ounce of cream. The use of Fairchild's 
peptogenic powder simplifies the process of peptonizing. The measure full 
of the powder, one tablespoonful of cream, four tablespoonfuls of milk, and 
four tablespoonfuls of water are mixed in a convenient vessel and maintained 
six minutes, with constant stirring, at a temperature so hot that it can barely 
be sipped. The casein by this process, though but partially digested, coag- 
ulates in flakes. I have, I think, improved this food for a large proportion 
of infants, especially for those over the age of three months and in the sum- 
mer season, by substituting barley-water for plain water. Barley flour is 
boiled dry seven days in a double boiler, so that a considerable portion of the 
starch is converted into dextrin, and the gruel is made by adding a heaped 
teaspoonful of the flour to eighteen of water. The dextrin in the barley 
gruel thus prepared is assimilated by the youngest child, and any starch- 
granules which may not be converted into dextrin separate mechanically 
the particles of casein, and aid in preventing the formation of curds in the 
stomach. 

Peptonized milk is a useful addition to the dietetic preparations for 
infants. By peptonizing is accomplished what physicians have long felt 
the need of — to wit, a mode of preparing cow's milk so that its casein coag- 
ulates in flakes like that of human milk. Milk employed for this purpose 
should be as fresh as possible, but unfortunately in hot weather, when there 
is most need of having a food for artificially-fed infants which bears the clos- 
est possible resemblance to human milk, in order to prevent the summer 
diarrhoea, much of the cow's milk when it reaches the cities, twenty -four 
hours after the milking, has begun to undergo fermentation, and is therefore 
unsuitable for peptonizing, though employed for this purpose. This is prob- 
ably one of the chief causes of the fact that peptonized milk not unfrequently 
disappoints our expectations. The peptonizing of milk rests on a scientific 
basis, and as clinical experience thus far has demonstrated the usefulness of 
milk prepared in this manner in the feeding of infants in a certain proportion 
of cases, it will probably continue to be regarded as one of the best substi- 
tutes for breast-milk. It has also been found useful for children with feeble 
digestion who have passed beyond the period of infancy. But recently a 
great improvement has been made in the preparation of cow's milk for the 
nursery by sterilizing it by the prolonged action of heat. It is placed in a 
steamer and maintained at nearly the heat of boiling water one and a half or 
two hours. This destroys any microbes which may have fallen into it, and 
it appears that the prolonged action of heat increases the digestibility of the 



LIEBIG'S FOOD. 77 

casein, by rendering it more liable to coagulate in flakes. Milk thus pre- 
pared, and given with some farinaceous food in which the starch is converted 
into dextrin or grape-sugar, will frequently agree with young infants and be 
fully digested without the aid of the peptogenic powder. 

It is known that infants prior to the third month can digest only a very 
small amount of starch, since the salivary and pancreatic glands, whose secre- 
tions convert starch into glucose — a necessary change in digestion — are almost 
rudimentary in the first months of infancy. In a monograph relating to 
Infant Diet written by Professor A. Jacobi. and revised, enlarged, and adapted 
to popular reading by Dr. Mary Putnam Jacobi, it is stated that the parotid 
glands, which, together, weigh 80 grains at fifteen months and 120 grains at 
two years, weigh but S-t grains at the age of one month. In several instances 
we weighed the pancreas taken from the bodies of infants who had died under 
the age of six months in the New York Infant Asylum. Its weight was very 
different in those whose ages were about the same : in several under the age of 
four months it was less than one drachm, and in some more than one drachm, 
but in no instance did it reach two drachms. The submaxillary and sublin- 
gual glands, which also secrete saliva, are comparatively insignificant in young 
infants, so that the combined action of the parotid, submaxillary, sublingual, 
and pancreatic secretions must be inadequate for the saccharification of the 
starch which ordinary farinaceous food contains during the first three or four 
months of infancy. 

But it is now ascertained that the salivary and pancreatic secretions are 
not the only agents by which starch is digested. The mucous surface fur- 
nishes an " epithelial ferment which assists in the change, so that the secre- 
tions from the buccal and intestinal surfaces materially aid in the digestion " 
(Revue des Sciences med., 1879, by Charles Eichert ; also remarks by Profes- 
fessor Flint, Jr., in Physiol, of Mmi). 

It appears, therefore, that young infants are able to digest a certain 
amount of starch, but a much smaller proportion than those who are older; 
and in the preparation of farinaceous food this fact should be borne in mind. 
Young infants can digest the two derivatives of starch — to wit, dextrin and 
grape-sugar — and it seems judicious, since they are more readily assimilated, 
to employ them in place of starch for sick children and for all children under 
the age of six months. 

The late Baron Liebig, who devoted considerable time in the last years 
of his life to the study of the food of infants, was the first who recommended 
the conversion of starch into grape-sugar by the action of the malt diastase, 
and this constitutes the special excellence of several of the infant foods which 
under other names have been largely used, and often with good results. But 
of all the farinaceous foods containing derivatives of starch which are found 
in the shops, and which have been used and recommended for infant feeding, 
barley flour with a considerable part of its starch converted into dextrin by 
the prolonged "action of heat (seven days at 212°), is probably one of the 
best, if not the best. Containing no admixture, it can be preserved with- 
out change for an indefinite time, and as the youngest child can digest dex- 
trin as well as peptonized milk, the combination of the two makes a useful 
food for infants in sickness as well as in health. 

But whatever may be the dietetic preparation designed for infant feeding. 
we have stated above that animal milk should form the basis. This fact 
is generally recognized, and the various proprietary foods either contain a 
large proportion of milk or milk is added to them in the nursery. Hence, 
during the last few years much attention has been directed to the milk-sup- 
ply of the cities, and in some of the cities it is under strict surveillance. It 
is now regarded as important that the health and condition of the cows in the 



78 ARTIFICIAL FEEDING. 

distant dairies should be closely inspected, that their milk should not be sent 
to market until several days after calving, and that the pastures in which 
they feed should not only have abundant grass and clover, but be free from 
foul water and noxious weeds. One at least of the companies that prepare 
food for the nursery insist on the observance of the above conditions in obtain- 
ing their milk from the farmer. Immediately after the milking the milk should 
be placed in open cans and, except in midwinter, surrounded by ice or cold 
water, so as to reduce its temperature as soon as possible to 60° or 65°. We 
have stated elsewhere that neglect to treat milk in this manner in a hot sum- 
mer day led to the development of tyrotoxicon in six or eight hours after the 
milking, and the poisoning of the guests of two hotels at Long Branch. In 
view of such cases the sterilization of milk, which we have recommended 
above, merits more than a passing notice. 

Dr. Soxhlet of Germany was among the first to recommend the steriliza- 
tion of milk by heat in an interesting monograph published in 1886. He 
alludes to the fact that particles of manure and other dirt fall into the milk 
in milking, and are liable to set up fermentation, which renders it unsuitable 
as a food. Drs. Jeffries. Warner, A. Jacobi, and A. Caille have also written 
instructive papers commendatory of the sterilization of milk by steam. Dr. 
Warner states that in his experiments milk thus sterilized has remained sweet 
five weeks. Soxhlet's mode of sterilizing milk is described by Dr. Caille as 
follows : 

Ten 5-ounce bottles are filled with milk to within half an inch of the 
neck. Into each bottle a perforated rubber stopper is pressed. The bottles 
are placed in a tray which is set in a pot of water. After the water has 
come to a boil and expansion has taken place, the glass stoppers are pressed 
into the perforated rubber stopper, thus hermetically closing each bottle. 
The milk remains in the boiling water fifteen to twenty minutes longer, and 
is for that length of time under pressure in a temperature of 212° F., which 
is sufficient to destroy all germs and impurities liable to produce fermenta- 
tion. Milk so prepared will keep sweet four to six weeks, according to 
Soxhlet. 

When the milk is to be used the bottle is put into hot water a few min- 
utes, until the contents are warm. The stopper is then removed and an ordi- 
nary nipple attached. A long feeding-tube may also be used in the usual 
way if desirable. Milk remaining in the bottle after the child has been fed 
is thrown away. 

The Arnold steam sterilizer (an American invention) has also lately been 
brought to the nStice of the profession. It is an ingenious apparatus fulfill- 
ing all the requirements, not allowing the escape of steam into the room, and 
furnished at a reasonable price. But, as Dr. Warner remarks, the simple 
kitchen steamer found at the hardware store answers the purpose if supplied 
with the proper bottles. Milk sterilized by steaming in this manner, and 
diluted with boiled water according to the age of the child, may agree with 
the youngest infant. 

Meigs and Pepper recommend for artificially-fed infants the admixture of 
prepared gelatin or Russian isinglass with the milk, and they state that in 
their practice, extending over many years, infants " have thriven better upon 
it than upon anything else." A piece of gelatin two inches square " is soaked 
for a short time in cold water, and then boiled in half a pint of water until 
it dissolves — about ten or fifteen minutes." To this is added, with constant 
stirring, the milk, containing some farinaceous food. Others who have used 
food prepared in this manner speak well of it. Although gelatin contains 
little nutriment, its presence may aid digestion, and a food recommended by 
physicians of such experience as Meigs and Pepper is worthy of trial in 



FOOD AFTER THE FIRST YEAR. 79 

cases of habitual indigestion or of intestinal catarrh in which the ordinary- 
food disagrees. 

Milk should be the chief article of food during infancy, but the older the 
infant becomes the larger should be the proportion of solid food given with 
it. After the first year the food may be made of such consistence as to be 
given with the spoon. In the second year and subsequently a pap may be 
made of stale bread boiled in water sufficient to cover it, and mixed with fresh 
milk, care being taken that all lumps are reduced to a pulp. Beef tea is a 
laxative, on account of the salts which it contains, as is also chicken tea ; but 
a small or moderate amount of it may be given once a day. Stale wheat 
bread or soda cracker should be crumbled in it, and soaked so as to be soft. 
If there be diarrhoea the ordinary beef tea should not be allowed, on account 
of its laxative effect, but the expressed juice may be given instead. Few 
vegetables are proper for infants under the the age of one year, but the 
potato, baked and mashed so as to be like flour, may be given at the tenth or 
twelfth month. It contains a large amount of starch, but appears to be- 
readily digested by infants of the age mentioned if given once a day in mod- 
erate quantity, with a little butter and salt added. In the second year a 
greater variety of food may be allowed, but the full diet of the table must 
not be given till after infancy, or at the age of three years. In the beginning 
of the second year the infant is weaned. He has twelve teeth, eight inci- 
sors, and four molars, which, with their broad surfaces, are designed for chew- 
ing. Let him have now, once or twice each day, in addition to the food 
which has previously been employed, a small piece of roast beef, rare done 
and cut very fine. Other meat, as mutton, may sometimes be given instead. 
After the age of eighteen months light puddings of farinaceous substances^ 
properly prepared, as of rice and corn meal, may be added to the dietary. 

All the teeth of the first set have appeared at the age of two years and 
five months, and the time has now arrived when a more marked transition, 
may be made from liquid to solid food. Certain fruits may be allowed, even 
before this period, as also the jellies of most berries and of fruits, which 
being deprived of seeds and parenchyma are for the most part readily 
digested, Avhile they give a relish to the farinaceous food with which they 
are eaten. Pastries as ordinarily made, whatever fruits they may contain, 
are too rich and indigestible for young children. The following judicious 
rule for the preparation of fruits for children, copied in popular treatises on 
hygiene of infancy and childhood, is from Murray s Modern Coohery Booh : 
. . . . " Put apples sliced, or plums, currants, gooseberries, etc., into a 
stone jar, and sprinkle among them as much Lisbon sugar as necessary : set 
the jar in an oven or on a hearth, with a teacupful of water to prevent the 
fruit from burning, or put the jar into a saucepan of water till its contents 
be perfectly done. Berries and fruits thus prepared and the fruit jellies are 
best eaten spread on bread and butter or on soda crackers." 



80 BATHING, CLOTHING, SLEEP, EXERCISE, 



CHAPTER IX. 

BATHING, CLOTHING, SLEEP, EXEBCISE. 

Bathing is now recognized in all civilized countries as one of the chief 
promoters of bodily comfort and health. The first bathing of the infant, 
which is immediately after birth, should be in water at a temperature a little 
below that of the blood — namely, at about 96° — after which the general 
bath is inadmissible until the navel-string is detached. In the infant reaction 
of the surface when chilled is tardy and uncertain, and therefore there is 
great danger of catching cold when the surface is cooled by water and does 
not quickly react. It is a matter of daily observation that infants become 
chilly and their extremities remain cool in a medium, whether air or water, 
in which older children and adults would have comfortable warmth. There- 
fore they are liable to contract bronchitis, sore throat, intestinal catarrh, or 
other inflammation from very slight exposures. This fact must be borne in 
mind in considering the subject of bathing. 

During the first year after the detachment of the navel-string the bath 
should be employed daily, but not longer than three minutes, during which 
time thorough ablution can be performed. Different authorities disagree in 
regard to the proper temperature of the bath during the first months of 
infancy. Steiner of Prague, a high authority in children's diseases, says : 
" During the first nine months the infant should have a daily bath a little 
above blood heat," but most authors recommend a temperature a little below 
blood heat. In my opinion it should be at 92°, which is considerably below 
blood heat, but which communicates a moderately warm sensation to the hand. 
After the age of ten months, or even of eight months for vigorous children, 
the temperature of the bath may be reduced to 90°, and it should not be 
lower than this during the remainder of infancy, or if it be used a little 
lower care should be taken to produce reaction by brisk rubbing and exercise 
after a short bath. At the close of infancy, or at two and a half years, the 
temperature may be still further reduced, but it should not, even for the most 
robust children of eight or ten years, be below 78°, which is recorded on our 
thermometers as the temperature of summer heat, and is about that of our 
northern lakes during midsummer. 

The rules given in the books, not to bathe or direct a child to be bathed 
immediately after eating or after much exercise, when the pores of the skin 
are perspiring, should be heeded. The head should first be wet with the 
water, and castile soap should be applied over the surface to ensure cleanli- 
ness. The strongly-scented toilet soaps sometimes contain rancid fats or 
other deleterious substances, and should be regarded with suspicion. In hot 
weather a daily bath is advisable, but in the cooler months it is sufiicient if 
the child bathe twice or three times in the week. If, from lack of conveni- 
ences or for other reasons, general bathing be dispensed with and the surface 
be washed from a basin or bowl, cooler water may be used than would be 
proper for the general bath, and a longer time to complete bathing would 
evidently be required. The bath-room should be comfortably warm, and 
after the bath the surface should be briskly rubbed with flannel or, in case 
of older children, with a suitable coarse towel, and exercise afterward encour- 
aged to ensure full reaction. In New York, in one of the largest and best 
manaired asylums, both boys and girls are allowed to bathe in bath-houses in 
the Hudson when the water and weather are not too cool. 



CLOTHING. 81 

It may be well to add to these general remarks on bathing the recent 
remarkable statement of a high authorit}' on thermometrie observations and 
temperature, that during hot days a bath in hot water, employed in the hours 
of greatest atmospheric heat, tends to reduce the heat of body and to pre- 
serve its normal temperature during the remainder of the day. Wunderlich 
says : " In tropical countries and in very hot seasons no means of cooling is 
so lasting as a bathe or douche of very warm water." 

Clothing. 

One of the most important duties of the mother or nurse is the selection 
of clothing for children which will be suitable for their age and the season. 
In the matter of dress, as in that of diet, many errors are unconsciously 
committed. In a room of proper temperature, which during the cool months 
should Idc 70° for infants and QS° for children old enough to run about, the 
head should never be covered unless in case of young infants ; but the sides 
of the head, as well as the neck and shoulders, may be lightly covered in 
sleep. It is the common practice to leave off the '' bellyband " which is 
applied after birth when the infant has reached the age of three or four 
months ; but from the fact that infants so often take cold, especially at night 
by throwing off bedclothes, both in cool weather, when the temperature of 
the apartment may fall below 70°, and in summer, when there are currents 
of air through open windows, I advise the continuance of the band during 
the first year or eighteen months. In the summer it should be made of light 
merino and in the winter of flannel. It should never be so thick and heavy 
as to be uncomfortable, or so snug as to interfere in the least with the free 
movements of the chest and abdomen in respiration. It should extend to 
and not over the ribs, and should be secured either with safety-pins or a few 
stitches. If excoriations or prickly heat appear on the skin under the band 
in hot weather — a very common eruption in infancy — the surface should be 
dusted with subnitrate of bismuth or a mixture in equal parts of lycopodium 
and oxide of zinc, and a single layer of linen should be applied over it and 
under the band. If the eruption be severe, it might be best to substitute a 
linen or soft muslin band for a time in place of the merino. 

A cardinal principle in the clothing of children is that the garments should 
always be so loose as not to interfere in the least with the functional activity 
of organs. The fitting and putting on of the dress is left too much to the 
discretion of the nurse, who is usually ignorant of the important facts in 
physiology, and unwittingly and with the best intentions injures her charge. 
I have often interposed to loosen the dress of young infants, which was so 
tight as sensibly to embarrass respiration ; and the case of a new-born infant 
has been reported to me in which it seemed probable that death resulted from 
this cause. Infants especially, who are so liable to pulmonary collapse and 
intestinal hernia, should have loose covering of both chest and abdomen. 
Pressure over the stomach always feels uncomfortable, and this organ, almost 
as much as the lungs, needs full expansion and free movement in order to 
perform its function of digestion properly. The same is true also of the 
intestines, but they tolerate compression better, and their movements are less 
impeded than those of the stomach by too tight dressing. Another part 
where too snug an application of the dress does very great harm is the neck, 
since moderate pressure in this region may retard the circulation of blood 
through very important vessels — to wit, those which supply the brain or return 
blood from this organ. The dress about the neck should always be so loose 
that the four fingers of the nurse can be readily introduced underneath it. 
Skirts upon girls are sometimes supported by being tied tightly around the 



82 BATHING, CLOTHING, SLEEP, EXERCISE. 

waist and over the stomach. This should never be allowed, but they should 
always be supported by shoulder-straps and be loose around the waist. 

Clothing protects the body according to its thickness and the feebleness 
of its conducting power of heat. Woollen, fur, and feather garments have 
very low conducting power, and wool, from its plentiful supply and cheap- 
ness, must always be the material which is chiefly worn in the winter season ; 
while cotton, and in still greater degree linen, are active conductors of heat, 
allowing its quick escape from any part of the body which it covers, and 
they are therefore the proper material for summer clothing. 

The color of the garment matters little as regards the escape of heat from 
the body, for whatever its color its surface next the body is necessarily dark 
from the exclusion of light ; but the color is important as regards the 
absorption of heat from the atmosphere and the solar rays. Black has the 
highest absorptive power, while white has the least, and the mixed colors 
have absorptive powers which are intermediate. In experiments made with 
shirtings of different colors, while white received 100° F., black received 
208° F. A light color is therefore the best to dress children in during the 
hottest weather. 

The covering which is proper for the head of a child when outdoors must 
evidently vary considerably in different seasons and in different states of 
weather. Many a young child with scanty growth of hair has contracted 
that painful disease, inflammation of the ear, followed perhaps by a protracted 
discharge and more or less impairment of hearing, in consequence of taking 
cold from insufiicient covering of head and ears in inclement and changeable 
weather ; even leaving off accidentally a band or tie which a child is accus- 
tomed to will sometimes give it a cold. 

In this connection I wish to call attention to the common and dangerous 
practice among the poor of allowing children to go bareheaded in the sun 
during the season when the atmospheric heat is highest. Not a summer 
passes in which I do not meet cases of inflammation of the brain which I 
believe to be largely due to exposure to the sun's rays. There is no better 
and safer covering for the head of a child who is allowed to go in the open 
air during the hot weather than the light, cool, and inexpensive straw 
hat. 

The feet should always be warm and dry, the shoes worn in wet weather 
being waterproof ; and special care should be taken in the selection of shoes 
that they be pliable and loose, so as to allow freedom of growth without com- 
pression of any part. If during the period of growth proper precautions are 
taken in this respect, the chiropodist would have little to do in subsequent 
years. Corns, bunions, and ingrowing toe-nails originate from shoes hard and 
unyielding or too tightly fitting. 

Sleep. 

The newly-born infant until about the age of six or eight weeks requires 
not less than twenty -one hours' sleep each day. It sleeps, therefore, most of 
the time when not awake for the purpose of nursing, bathing, and change of 
clothing. If it do not have this amount of sleep and be wakeful, it is prob- 
ably not well. After the eighth week it requires less and less sleep with 
advancing age, and at the end of the first year fourteen hours of sleep each 
day suffices. At the age of eighteen months about twelve hours of sleep are 
needed, a part of which should be in the middle of the day. At the age of 
two and a half or three years, and subsequently during childhood, about ten 
hours are required at night, and if the child be tired or sleepy in the day- 
time it should be allowed to sleep. Sufficient sleep is essential for the nor- 



EXERCISE. 83 

mal development of the body and the normal functional activity of the, 
organs in infancy and childhood. 

During sound sleep the senses no longer receive and communicate impres- 
sions. They enter into the state of sleep in the following order : Sight is 
first lost, and then touch, taste, smell, and lastly hearing. In sound sleep 
also the frequency of the respiration and pulse is slightly diminished. Exci- 
tation of any of the senses has a tendency to prevent sleep. A bright light, 
rough handling, and loud noises render young children wakeful, and, if there- 
by deprived of the needed sleep, fretful. Slight excitation of certain of the 
senses, as by a low humming voice or gentle rocking, on the other hand, tend 
to procure sleep. The time of soundest sleep is about one hour after its 
commencement, after which it becomes gradually less profound until the 
child awakens. The child should be habituated to taking its sleep at a cer- 
tain hour, and if it be ivell and not subjected to any unusual excitement, it 
will be drowsy and will sleep readily when that hour arrives. In the asylums 
of New York, where from long and abundant experience the management of 
children is systematized, infants and the younger children are usually put to 
bed between six and seven, and the older children between seven and eight, 
o'clock, the last meal being light and readily digested. 

Various causes produce wakefulness in children. We have already alluded 
to strong impressions upon the senses. A swollen and tender gum, indiges- 
tion with flatulence and colic, eczema with tenderness and itching, as well as the 
more serious forms of sickness, produce wakefulness. Unpleasant and excit- 
ing sensations of whatever kind, reaching the brain, keep up a state of 
excitement and prevent its repose. The fretful and sleepless baby in the hot 
and stifling air of the tenement-house in the heat of summer soon falls asleep 
when taken to cooler air outside. 

It is scarcely necessary to call attention to some accepted and important 
facts regarding the dormitory of children. Free ventilation is required either 
through ventilators or through the windows, slightly raised in winter, and 
more widely open in summer. A small room should not contain more than 
two children, and the temperature of the sleeping apartment should be at 
about 68°. A temperature too cool causes wakefulness. 

The amount of blood circulating in the brain in sleep is less than when awake, 
and too active a circulation, as from fever or much excitement, causes wake- 
fulness. If the head be unduly hot, and in the infant the anterior fontanel 
pulsate forcibly, a cloth wrung out of cold water should be applied over it, 
and a general bath or hot foot-bath shouW be used in order to diminish the 
cerebral circulation. On the other hand, if the brain be not properly nour- 
ished in consequence of poverty of the blood, as is sometimes the case with 
pallid and scrofulous children, the diet should be more nutritious and iron 
may be needed. 

If the sleeplessness continue when all causes so far as possible have been 
removed, medicinal treatment will be necessary. Frequently in families 
before the physician is summoned, the so-called soothing syrups have been used, 
which contain an opiate, and the use of which should be forbidden. The safest 
remedy is one of the bromides, which may be given dissolved in water in 
three-grain doses to an infant between the ages of six and twelve months, 
and one grain additional should be added for each year, or the aniseed cordial 
of the National Formulary. The dose if required may be repeated after two 
hours. 

Exercise. 

Exercise is an important hygienic requirement. Harm often results from 
modes of exercise which are not adapted to the age. Occasionally I meet 



84 BATHING, CLOTHING, SLEEP, EXERCISE. 

cases of permanent bow-leg which have manifestly resulted from attempts to 
make infants stand at the age of four or five months. They should never be 
encouraged to walk or stand till about the age of one year, and if they do at 
the age of nine or ten months let it be voluntary, and not taught by stand- 
ing them upon their feet. In case of infants with rachitis — which disease is 
common in cities, and is characterized by a lack of lime-salts in the bones, 
and can be detected by great backwardness in teething — attempts to stand 
or walk for any length of time should be discouraged till by the use of lime- 
salts and cod-liver oil and improvement of the general health the rachitis is 
cured. Much of the permanent deformity which mars the beauty and sym- 
metry of adult life originates in rachitis and might have been prevented. 

The infant before he is old enough to stand takes sufficient exercise in a 
way that is natural and harmless. Let him lie upon his back in the crib or 
on the floor, with a blanket under his body and pillow under his head, with 
all his clothes loose, so as not to restrain the free movement of his limbs. A 
healthy infant seems to enjoy this attitude, moving all his limbs sufficiently 
to give them the required exercise, and evincing his delight and exuberance 
of life by utterances which are as expressive as words. 

In the cool months of our latitude infants should not be taken outdoor 
until the age of three months, and then only for a brief time in the warmest 
part of the day ; but in the summer they should begin to receive outdoor air 
and exercise at the age of one month. In warm weather the face should 
never be covered by a veil or otherwise, and air and light should have free 
access to it. The rays of the sun, however, from a clear sky should be 
excluded, either by a parasol or the shade of trees or houses or by the carriage 
in which the infant is conveyed. In cold weather or when there is a strong 
wind the protection of a veil is needed. Rude tossing of infants, which is 
common in families, should always be forbidden. Its effect on the cerebral 
circulation is likely to be bad, and it involves risk of serious accident. In 
one instance to my knowledge death resulted from injury received in this 
way. 

Walking, as it is the natural, so it is the best, exercise for the older infants 
and during the period of childhood. It promotes digestion when not carried 
to the extent of fatigue, and gives gentle exercise to all the muscles. The 
baby-carriage answers a useful purpose when combined with walking. With 
the ordinary hired nurse it is safer for the infant to be taken out in this 
vehicle than in the arms, for if the nurse in careless walking should trip great 
harm might result. In one instance which came under my notice convulsions 
and idiocy were plainly referable to the fall of an infant from its nurse's 
arms upon its head. 

The ordinary lawn sports of childhood, as croquet for both sexes, play- 
ing ball or quoits for boys, which are rendered more exciting by the spirit of 
rivalry, are also useful for muscular exercise and development, while they 
involve little danger. The swing affords a pleasant exercise, and with the 
propulsion required it gives gentle but efficient activity to most of the 
muscles. 

Many of the gymnastic exercises are too severe, involve too much risk 
of ruptured tendons, sprained joints, and even of dislocated or broken 
limbs. 

Among all the ingenious inventions to provide sports and pastimes for 
children, there are none better than gardening and farming where facilities 
will allow them, conjoined with the ordinary household duties. The healthy 
and robust development of the farming population, their almost complete 
immunity from rachitic and scrofulous ailments, is attributable to their out- 
door mode of life and the many kinds of healthful work which farm-life 



FEATURES, ETC. IX DISEASE. 85 

requires. Such work is always in the highest degree beneficial for children 
old enough to participate in it, while it develops the habit of productive 
industry. 



CHAPTER X. 

DIAGNOSIS OF INFANTILE DISEASES. 
General Observations. 

Diseases in early life differ in important particulars from those occurring 
in maturity. Some which are common in the former age are unknown or are 
rare in the latter, and those which occur equally at all ages often present 
peculiar symptoms and a peculiar clinical history in the young. Therefore 
physicians who are skilful in treating adults may be unskilful in treating 
children. Excellence as a physician of children can only be achieved by 
special and continued study of their ailments. 

Again, as regards the diseases of infancy, in which period there are a great 
amount of sickness and a large mortality, diagnosis must evidently be made 
from the objective symptoms — from examining the features, attitude, utter- 
ances, the pulse, respiration, etc., and inspecting the surfaces, so far as they 
are accessible to view, and the eliminated products. We lack for this age the 
important information which speech affords. Some general remarks, there- 
fore, in reference to the appearances and functions of the system in early life, 
and the changes which they undergo in various pathological states, seem 
requisite in order to a clearer appreciation of the symptoms and more ready 
diagnosis of individual diseases. 

Features, External Appearance of the Head, Trunk, and 

Limbs in Disease. 

In the new-born, as soon as respiration and the new circulation are estab- 
lished, the cutaneous capillaries become distended with blood and the skin 
presents a congested appearance. By the close of the first week this external 
hypersemia begins to abate, and is soon replaced by the normal capillary 
circulation. 

Icterus is common in the first and second weeks. Bouchut attributes it 
to mild hepatitis. A much more plausible view of its causation, and prob- 
ably the correct one, is that of Frerichs, who attributes it to the effect on the 
hepatic circulation of ligation of the umbilical cord. By ligation the current 
of blood through the umbilical vein to the liver ceases, the amount of blood 
in the hepatic capillaries, which connect with the branches of the vein, dimin- 
ishes, and then, according to Frerichs, by the law of diffusion, diversion 
occurs of a part of the bile from the hepatic cells into the capillaries, while 
the rest flows in the normal manner into the bile-ducts. The degree of jaun- 
dice is proportionate to the amount of bile which enters the circulation. 
Icterus neonatorum is ordinarily not a disease of importance. If the gen- 
eral health remain good, it subsides without medicine in the course of one 
or two weeks, when the circulation through the liver becomes equalized and 
regular. 

The surface or portions of the surface of the new-born often present for a 
few hours a livid color, due to the mode of delivery. Protracted lividity 



S6 DIAGNOSIS OF INFANTILE DISEASES 

occurs from atelectasis or malformation of the heart or great vessels ; lividity 
induced by exertion or excitement, while the respiration is normal, indicates 
malformation of the heart or vessels ; temporary lividity sometimes occurs in 
severe acute diseases, especially those of the respiratory organs ; lividity, 
whether temporary or permanent, is a sign of imperfect decarbonization of 
the blood. 

The cheeks of children are congested in febrile and inflammatory diseases, 
except in a cachectic or prostrated state of the system. Transient circum- 
scribed congestion of the face, ears, or forehead constitutes a reliable sign of 
cerebral disease. Strabismus occurring in connection with febrile reaction, 
oscillation of iris, inequality of pupils, and drooping of upper eyelids, also 
denote cerebral disease. The pupils are contracted during sleep, evenly 
dilated in death. 

Dilatation of the alse nasi during inspiration, with contraction of the eye- 
brows and a countenance indicative of suffering, attends severe inflammation 
of the respiratory organs. Absence of tears during the act of crying shows 
a severe and probably fatal form of disease in infants over the age of four 
months. 

Rapid wasting of the features, causing deep suborbital depressions, prom- 
inence and pointedness of the cheek-bones and chin, and hollowness of the 
cheeks, are signs of severe diarrhoeal malady ; the most striking examples of 
this sudden collapse of features are afforded by patients affected with cholera 
infantum. In severe cases of this disease the physiognomy, from a state of 
fulness and health, presents in a few hours such a wasted and senile appear- 
ance that the friends with difficulty recognize the features with which they 
are familiar. Muscular tonicity is also greatly impaired in this disease — that 
of the orbicular muscles of the lips and eyelids to such an extent that the 
mouth is open and the eyeballs exposed during sleep. Great emaciation 
occurring gradually is a symptom of subacute or chronic disease of a grave 
character, often of tuberculosis or chronic entero-colitis. 

Strabismus sometimes occurs in children who have no serious disease. It 
is then due to simple paralysis of one or more of the motor muscles of the 
eye. But when supervening upon other symptoms of a neuropathic charac- 
ter it is a grave symptom, indicating organic disease of the encephalon, as 
effusion, meningitis, etc. A permanently downward direction of the axes of 
the eyes, with smallness of the face and great expansion of the cranium, is a 
sign of chronic hydrocephalus. The scalp in this disease is tense, bald, or 
sparingly covered with hair, the fontanels and sutures open and enlarged, 
and the cranial bones yield to pressure. Great expansion of the cranium 
above the ears, while the frontal portion is not enlarged or but slightly, 
denotes hypertrophy of the brain. 

The appearance of the general cutaneous surface possesses much greater 
diagnostic value in the diseases of infancy and childhood than in those of 
adult life. The eruptive fevers, so common in the young and comparatively 
rare in the adult, reveal themselves to us in great part by the changes which 
they cause in the appearance of the integument. The peculiar color of the 
skin in constitutional syphilis, hereafter to be described, and which is more 
marked in infancy and early childhood than at any other age, is a diagnostic 
sign of great value in obscure cases. In the infant the cold stage of inter- 
mittent fever is manifested, not by muscular tremors, but by lividity, pallor, 
and the goose-skin appearance of the surface. 

Bulbous enlargement of the fingers and incurvation of the nails are signs 
of cyanosis, and therefore of malformation at the centre of the circulatory 
apparatus, or of tuberculosis or chronic pulmonary disease attended by mal- 
nutrition. Enlargement of the spongy portions of bones, causing prom- 



ATTITUDE— MOVEMENTS— THE VOICE. 87 

inences, softness, and bending of the bones, and consequent deformity of 
the limbs, patency of the fontanels, a large and square shape of the head 
from calcareous deposit external to the cranium, and delayed dentition, are 
among the signs of rachitis. 

In early infancy the glands of the skin and mucous surfaces, or which 
connect by their orifices with these surfaces, are slightly developed. There- 
fore, sensible perspiration and lachrymation are rare under the age of three 
months. A thick Meibomian secretion of a puriform appearance collecting 
between the eyelids is an unfavorable prognostic sign ; it indicates a state of 
great depression ; it is observed most frequently in cerebral and intestinal 
maladies shortly before death. Passive congestion of the vessels of the con- 
junctiva sometimes occurs under the same circumstances, due to feebleness 
of the heart's action and imperfect capillary circulation. It indicates the 
near approach of death. 

Attitude — Movements — the Voice. 

A sharp, piercing cry, head firmly retracted, flexure of the limbs with a 
degree of rigidity, abduction of the great toe, clonic or tonic spasm of the 
muscles, irregular movements of one or more limbs, with consciousness 
impaired or with mental hallucinations, are symptoms of grave disease of 
the cerebro-spinal system. Irregular muscular movements, partly controlled 
by the will and occurring during full consciousness, are symptoms of chorea, 
a disease nearly always ending favorably in children, though incurable in the 
adult. Contraction of the eyebrows, turning of the eyes and face from light, 
avoidance of noises as if painful, are signs of headache. Frequent carrying 
of the hand to the ear and pressing with the ear against the breast of the 
mother or nurse are symptoms of otalgia. Frequent carrying of the fingers 
to the mouth in connection with fretfulness or other symptoms of suffering 
indicates stomatitis, gingivitis whether from difficult dentition or other causes, 
painful pharyngitis, or some obstructive disease of the larynx. Frequent 
rubbing or pressing the nose may be due to intestinal worms or intestinal 
irritation from other causes. It may be due to coryza or headache. Fre- 
quent forcible rubbing or striking the nose should lead to a careful examina- 
tion and perhaps guarded prognosis. It often indicates grave cerebral disease, 
and may be a precursor of convulsions. 

In severe obstructive disease of the larynx the child is restless, moving 
from side to side. In most inflammations of the respiratory organs a semi- 
erect position gives most relief. The voice in severe laryngitis is often hoarse 
or indistinct, and is usually so in the pseudo-membranous form ; in pleuritis 
or pneumonitis it is restrained and abrupt, since the movements of the walls 
of the chest give pain. 

The voice in severe diseases of the abdominal organs is feeble and plain- 
tive. It is sometimes short and restrained in acute dyspepsia, in peritonitis, 
and in cases of great abdominal distension. The horizontal position gives 
most relief in abdominal diseases. In case of abdominal pain the patient 
often presses his hand upon the abdomen and flexes his thigh over it. Per- 
fect quietude, with feattires sunken and unchanged by smile or crying, is a 
symptom of severe and exhausting diarrhoea! affections. 

Respiratory System. 

The respiration of the infant under the age of six months is very irreg- 
ular, and it is more irregular the nearer the time to birth. If the new-born 
infant be closely observed, it will be seen to sigh often ; it breathes pretty 



88 



DIAGNOSIS OF INFANTILE DISEASES. 



uniformly and regularly for a moment, and then, without appreciable cause, 
the respiration is intermitted ; it holds its breath when it smiles or moves 
its head or even its limbs ; it is very subject to hiccup ; this is more common 
the first week of life than at any other age. So much is the breathing of 
the young infant disturbed by these causes that the number of respirations 
ordinarily varies in consecutive minutes. In order, therefore, to determine 
with accuracy the frequency of the normal respiration for this time of life 
it is necessary to take the average of several observations. 

At birth, while the function of the heart has for months been regularly 
performed, the lungs are still quiescent. The one organ has been active dur- 
ing the greater part of foetal development, the other is yet untried. Here- 
after, in the new order of things, so intimate is the relation between the heart 
and lungs that the proper performance of the function of the one is essential 
to that of the other. Therefore, the commencement of respiration and the 
return of circulation, which is modified and temporarily arrested at birth, 
are nearly simultaneous. Respiration begins in the first half minute of inde- 
pendent existence ; often, indeed, attempts to inspire occur before delivery is 
completed. The exceptions to this early establishment of respiration are 
after tedious or unnatural births. The establishment of the new circula- 
tion is a moment later. 

Respiration in Health. — As the air-cells at birth are closed, the estab- 
lishment of respiration is difficult. The air at first penetrates a few pulmo- 
nary cells, but gradually more and more are inflated through the forcible 
inspirations which the crying of the infant produces, till after a variable 
time respiration becomes easy and complete. If the cry be feeble, and espe- 
cially if with this feebleness there be considerable congestion of the brain, 
the result of tedious birth, the full establishment of respiration is in a cor- 
responding degree gradual and slow. 

The frequency of the respiration in health should be ascertained in order 
to determine whether in a given case it be abnormally accelerated. The fol- 
lowing table embodies the result of observations which I have made in order 
to determine the normal frequency of respiration in the first year of life : 



Normal Infantile Respirations (jmmhei 


per 


minute^. 








Age. 






From first 


From close 


From close 


Close of 


Close of 






half hour to 


of first week 


of first 


third to close 


sixth month 






close of first 


to close of 


month to 


of sixth 


to close of 




First 


week. 


first month. 


close of third. 


month. 


first year. 




half 
hour. 






































aj 




35 


a 


ID 


. 




(£, 




&> 
























































"Id I 


is 


-3 


^ 


"3 


^ 


oo 


? 


CO 






<1 


< ! 


< 


< 


< 


< 


< 


< 


<! 


< 


Number of observatious. 


29 


28 


14 


13 


13 


16 


10 


25 


7 


19 


6 


Extreme number of res-l 










1 




1 








pirations per minute . 125-104 


32-64 


40-64 


40-96 


28-60 i 


32-68 


28-52 


36-88 


24-40 


28-64 


24-36 


Mean number of respira- 






















tions per minute ■ • ■ 48.5 


52 


52 


59 1 45 


51 


39 


54 


33 


41 


29 



As the child advances from the age of one year, the number of respi- 
rations per minute gradually diminishes, but through the whole period of 
childhood it remains greater than in the adult. At the age of five years, 
when the child is quiet but awake, it is about 27 ; at the age of ten years, 
about 22. 

Respiration in Disease. — In cerebral diseases the respiration becomes 



RESPIRATORY SYSTEM. 89 

slow, and, if somnolence occur, intermittent and accompanied by sighing. 
In young infants, in the drowsiness which supervenes when the blood is 
imperfectly decarbonized, during severe attacks of capillary bronchitis or 
broncho-pneumonia, respiration is likely to be intermittent. 

In inflammatory diseases of the larynx and trachea respiration is but 
slightly accelerated, and, if there be no obstruction, its rhythm is normal ; 
if there be obstructive disease its rhythm is altered ; the inspiratory act is 
lengthened. In bronchitis respiration is accelerated in proportion to the 
degree of extension downward of the inflammation. It is in no disease more 
accelerated than in severe capillary bronchitis. 

In pleuritis and pneumonitis the respiration is accelerated in proportion 
to the extent and acuteness of the inflammation. Inspiration ending abruptly 
and succeeded by an expiratory moan is a symptom of both pleuritis and 
pneumonitis in their acute stages. In certain cases of irritative or inflam- 
matory disease of the abdominal organs respiration presents a similar charac- 
ter ; it is modified in this manner in consequence of the pain experienced in 
movements of the diaphragm. Ordinarily, however, in abdominal diseases, 
respiration is nearly natural. 

The cough is an important diagnostic symptom. It is loud and sonorous 
in spasmodic croup, hoarse or harsh in true croup, clear and distinct in bron- 
chitis, suppressed and painful in the early stages of pneumonitis and pleuritis, 
convulsive and with more inspirations than expirations in pertussis. A cough, 
due to coexisting bronchitis is one of the first and most constant symptoms of 
measles. Typhoid and remittent fevers, difficult dentition, intestinal worms, 
irritating ingesta, and severe burns sometimes give rise to a cough which is 
nearly dry and painless. Occurring in such diseases, it is sometimes depend- 
ent on more or less bronchitis, to which the primary disease has given rise. 

A strongly-marked nasal or palatal cry is present in syphilitic ozaena, 
hypertrophied tonsils, and paralysis of the soft palate. If these can be 
excluded it indicates retropharyngeal abscess. On one occasion Pollitzer 
heard this cry in a baby that the mother said was well ; but he introduced 
his finger in the fauces, felt the expected swelling, and by an incision evac- 
uated a considerable amount of pus. 

An excessively prolonged, loud-toned expiration, with normal inspiration 
and without dyspnoea, is, according to Pollitzer, an early symptom of chorea, 
sometimes preceding all other symptoms. He was once called to a child, 
apparently well and asleep, in whom this symptom had continued two hours, 
and was supposed by the mother to indicate croup. Later the ordinary 
symptoms of chorea appeared. The same author regards a high thoracic, 
continued sighing inspiration as almost pathognomonic of weak heart and 
of certain cases of acute fatty heart. Unlike the condition in laryngeal 
stenosis, while the diaphragm is nearly inactive the accessory muscles of 
inspiration act strongly. This symptom occurs early, antedating the lividity, 
pallor, weak pulse, and cold extremities. 

A distinct pause after each expiration, ascertained in a quiet room by 
placing the ear close to the mouth, distinguishes laryngeal catarrh from croup 
(Pollitzer). Stridulous inspiration usually indicates acute laryngeal catarrh, 
but I have, in a considerable ntimber of instances, been asked to prescribe for 
infants with stridulous respiration which commenced early, perhaps in the 
first or second month, and continued night and day till about the close of 
the first year, when, in the development of the child, it ceased. It is 
attended by no dyspnoea or suffering, does not interfere with the nutrition 
or growth, is not benefited by any known treatment, and it seems that it 
may exist within physiological limits. 

A shrill, loud cry. night after night, in sleep, while the child is well in the 



90 



DIAGNOSIS OF INFANTILE DISEASES. 



day-time, is probably due to dreams, and it may be treated by a large dose 
of quinine at bed-time, but a full dose of the bromide of potassium or sodium 
is perhaps more likely to give relief. A cry lasting five or ten minutes and 
occurring several times in the day indicates spasm of the bladder, especially 
if dysuria be present. It is best treated by belladonna, provided that there 
be no calculus. A cry during defecation indicates fissure of the anus, and 
is to be treated by an ointment of zinc and belladonna. A violent and pro- 
tracted cry, with restlessness, pressing the head' on the pillows or breast of 
the nurse, and frequent carrying of the finger to the ear, indicate otalgia. 



Circulatory System. 

In all ages and countries the pulse has been considered an important 
symptom, both in diagnosis and prognosis. It aids the practitioner in deter- 
mining, approximately, not only the character, but the gravity, of diseases. It 
is somewhat remarkable, from the importance which is attached to the pulse 
in medical practice, that its natural frequency and its character in infancy are 
not more accurately known. It is true that eminent observers, as Trousseau 
and Valleix, have published statistics relating to the infantile pulse in health, 
but these statistics disagree, and therefore do not aiford a reliable standard 
with which to compare the pulse in disease. Moreover, some published 
statistics of the pulse possess but little value from the small number of 
observations ; some from the fact that records of the infantile pulse are 
grouped with those of older children ; and others because the state of the 
infant as regards its activity or emotions is not mentioned. 

Pulse in Health. — It is not easy to collect statistics of the pulse 
during the period of infancy which are entirely free from error, since slight 
derangements of the system in the infant frequently occur which are not 
manifested by any marked symptoms, but which produce acceleration of 
pulse. In collecting the following statistics sources of error, so far as pos- 
sible, were avoided. 

The movements of the heart commonly begin about one-eighth of a min- 
ute after birth. They are at first slow, the ventricular contractions not 
numbering more than eight or ten by the close of the first quarter minute. 
In the second quarter the cries are vigorous, and the pulse now is rapidly 
accelerated, rising commonly above 120, and sometimes above 160 beats, per 
minute. In fifty-seven observations of the pulse in healthy infants during 
the first half hour of life, after the first quarter of a minute I found that the 
extremes, with one exception, were 104 and 164 — average, 139. 

Table of Infantile Pulse in Health. 



Number of ob- 
servations . . 
Extremes . . . 
Mean 







1 

From close of 


From close of 


First 


ee . 


first week to 


first month to 






1 close of first 


close of 






I month. 


third. 1 

II 


Awake 




Awake. 




Awake. 


j 


Quiet; 


P' 


Quiet ; 


a 


Quiet; 


ft 


movinij 


S 


moving 


D 


moving 


0; 


slightly; 


< 


slightly; 


< 


slightly; 


-< 


nursing. 


nursing. 




nursing. 




22 


16 


10 


10 


15 


17 ■ 1 


104-152 


108-140 


! 124-160 : 104-144 


112-148 


104-132 \ 


126 


122 


1.39 


118 


182 


118 



From close of , From close of 

third month to : : sixth month 

close of ': to close of 
sixth. first year. 

:il 



Awake. 
Quiet; 
moving 
slightly; 
nursing. 



25 

112-146 

129 



104-116 
108 



Awake. 
Quiet; 
moving 
slightly"; 
nursing. 



20 

112-144 

127 



109 



CIRCULATORY SYSTEJL 



91 



" M. Ledeberder,"' says Bouchut, '' could only count the pulse in the first 
minute of life in six children, and he has observed from 72 to 94 pulsations." 
Yalleix estimates the pulse between the ages of two and twenty-one days at 
87. Trousseau states that the pulse in the first week of life varies from 78 
to 150 ; and Dr. Gorham"s observations are in the main similar to Trousseau's. 
My observations, as seen from the above table, do not correspond with the 
assertions of Ledeberder and A^'alleix. Indeed, if there were no conflicting 
testimony there would still be a strong presumption that these authors are in 
error, for we would not suppose that the pulse of the infant, in whom there 
is greater functional activity both muscular and visceral, would fall so much 
below that of the foetus. It is probable from the expression, '• could only 
count the pulse .... in six children,"' that Ledeberder. and perhaps Yal- 
leix, counted the pulse in the wrist, which, with exceptional cases, is very 
difiicult and often impossible in the first week of life, and that they missed 
some of the beats, or, not unlikely, sometimes counted their own pulse. 
Immediately after birth there is so little force of the ventricular systole, and 
the extreme arteries, therefore, of the system pulsate so feebly, that neither 
in the limbs nor at the anterior fontanel can the frequency of the pulse be 
readily ascertained. It can be readily and accurately ascertained only by 
auscultation or by placing the hand on the precordial region, or directly after 
birth by the pulsations in the umbilical cord. 

The average pulse of the healthy infant in the first and second months is, 
according to Trousseau, 137 per minute, 128 from the third to the sixth 



month, and 120 from the sixth to the twelfth 



ith. It is seen that his 



observations agree closely with mine as regards infants who are quiet, but 
awake. One point of interest established by the above statistics is the great 
diminution in the frequency of the pulse in sleep. 



Puhe 


diu 


ing or after Active Movements or Great Mental Excitement. 






Age. 






Close of first 


Qose of first 


Close of third 


Close of sixth 






First week. 


week to close of 


to close of third 


to close of sixth 


month to close 






first month. 


month. 


month. 


of fii-st year. 






140 


162 


176 


132 


132 






160 


156 


152 


148 1 


144 






140 


140 


158 


148 1 


152 






152 


152 


144 


144 1 


182 






. . 


152 


156 i 


198 






• • 


180 


156 ; 

1 


160 


Extremes 


. . 140-160 


146-162 


144-180 


1 
132-156 i 


132-198 


Mean . . 


148 


152 


160 


147 1 


156 



It is seen by the above table that by active exercise or great mental excite- 
ment the pulse may become as rapid as in grave diseases. There is greater 
acceleration of pulse from the emotions and from exercise in feeble than in 
robust children. Obviously, in order to determine to what extent the pulse 
is accelerated in disease it is necessary that it should be counted during a 
state of quietude. As the age increases it is less and less influenced by the 
emotions and physical exertion ; still, during the whole period of childhood 
such influences do have more or less eff"ect on its frequency. 

Pulse in Disease. — Febrile and inflammatory diseases produce greater 
acceleration of pulse in early life than in maturity. Diseases or derangements 



92 DIAGNOSIS OF INFANTILE DISEASES. 

of system, particularly those of the digestive organs, which do not materially 
affect the pulse in the adult, often cause acceleration of it in children. The 
febrile pulse of early life usually has exacerbations in its frequency. These 
commonly occur in the latter part of the day. Distinct and more or less reg- 
ular febrile exacerbations and remissions are common in several diseases of 
early life, some of which are serious, while others involve little danger. 
Among these diseases may be mentioned difficult dentition, intestinal worms, 
incipient meningitis, and constipation. An intermittent and irregular pulse 
is common in fully-developed meningitis and certain other severe organic 
diseases of the encephalon. It may be due also to disease of the heart, and 
it also occurs in some children from temporary disturbance of the digestive 
function. The pulse is slow in compression of the brain and in sclerema of 
the new-born. 

Animal Heat. 

The internal temperature of the body in health is uniform. In 33 infants 
under the age of seven days M. Roger found the average temperature 98.6° 
Fahr., while in 25 from four months to fourteen years old it was 99°. The 
external temperature alone varies in health according to the temperature of 
the atmosphere. 

Elevation of temperature above the normal standard is a sign of inflam- 
matory and febrile diseases. The increase of heat varies according to the 
nature of the disease and its type. In favorable cases of inflammation and 
in simple fevers it is not ordinarily more than two or three degrees. The 
greater the severity and malignancy of inflammatory and febrile diseases the 
greater the elevation. An elevation of more than six degrees' indicates a 
malady which is likely to prove fatal. It is rare that the temperature, even 
in fatal cases, rises above 107°. In measles, in the eruptive stage, it is from 
101° to 103°; in scarlatina from 102° to 104° if no complication exist. In 
diphtheria the temperature is elevated at first, but it frequently falls to nearly 
the normal during the stage of profound toxaemia. 

Reduction of the internal temperature is an unfavorable prognostic sign ; 
it is observed a few hours before death in infants who are greatly reduced by 
certain chronic diseases, as entero-colitis. In these cases the tongue, and even 
sometimes the breath, communicate to the finger or hand a sensation of cold- 
ness. 

The importance of thermometric observations as an aid to the diagnosis 
of children's diseases is within a few years more fully recognized by the pro- 
fession. Two diseases which in their commencement present very similar 
symptoms often vary as regards the temperature. Thus, meningitis, present- 
ing in its first stages symptoms very similar to those of typhoid fever, has a 
lower temperature till an advanced stage, when the amount of heat increases. 

Digestive System. 

Inspection of the buccal and faucial surfaces discloses some of the most 
frequent local diseases of infancy, as the various forms of stomatitis, and 
others which, though not frequent, involve great danger, as gangrene of the 
mouth, diphtheria, and retro-pharyngeal abscess. Inspection of the tongue 
aids in determining in many cases whether the disease be pursuing a favor- 
able course or has become asthenic and is exhausting the vital powers. 

Febrile movements, even when slight, give rise to coating of the tongue 
and intumescence and distinctness of its follicles. The eruptive fevers are 
attended by changes upon the buccal and faucial surfaces which possess 
diagnostic and prognostic value. Hypersemia of these surfaces appears early 



DIGESTIVE SYSTEM. 



93 



in rubeola and scarlatina prior to those phenomena which are justly regarded 
as pathognomonic. It is therefore often an important sign in the initial period 
of these diseases when the diagnosis is obscure. The appearance of the 
fauces in diphtheria and croup, indicating not only the nature of the disease, 
but its gravity, need only be referred to in this connection. 

Inspection of the buccal and faucial surfaces sometimes enables us to 
form a probable opinion in reference to the nature of diseases which are 
seated in other parts. In the infant protracted stomatitis is a common 
accompaniment of chronic diarrhoea, and it indicates its inflammatory 
nature. 

Vomiting is more frequent in infancy than in childhood, and in either 
period than in adult life. It is common in cerebral affections, and is one of 
the first symptoms of scarlet fever, and is not uncommon, though less fre- 
quent, in the commencement of other essential fevers and of acute inflam- 
mations. It is a symptom of indigestion, entero-colitis, cholera infantum, 
and intussusception ; it is common also after the paroxysmal cough of per- 
tussis, and not infrequent in the bronchial inflammations of young infants. 
In both these diseases it is excited by the muco-purulent matter upon the 
faucial surface. 

Intestinal gas is in part secreted or exhaled from the mucous membrane, 
as the experiments of Hunter and others have shown, and is in part the 
product of chemical changes in the food. A certain amount of gas in the 
intestines is normal ; it subserves a useful purpose. An abnormal amount 
of it is common in various diseases, as indigestion, chronic entero-colitis, peri- 
tonitis, typhoid fever. It is a frequent cause of gastralgia and enteralgia in 
the infant. In scrofulous or feeble infants with impaired muscular tonicity 
and faulty digestion the abdomen is often habitually more or less distended 
with gas, which does not, under such circumstances, give rise to pain or other 
local symptoms ; it has significance as showing 
the general condition of the child. 

In the rachitic, whose thorax is compressed 
and liver often enlarged, while the vertebral 
column is shortened, the abdomen is commonly 
protuberant. In feeble children, not decidedly 
rachitic, whose lungs are seldom fully inflated, 
and whose chests are consequently depressed, 
the abdomen is also prominent. The accom- 
panying woodcut represents one of these cases 
presented for treatment at the Out-door Depart- 
ment at Bellevue. 

In feeble children who have suff'ered from 
repeated and protracted attacks of bronchitis, 
and whose chest-walls are consequently de- 
pressed, a similar abdominal prominence occurs. 

Retraction of the abdominal walls is common 
in meningitis and in many exhausting diseases. 
Tenesmus is a symptom of intussusception in 
the infant and of colitis in children. 

Much light is thrown on the character of 
intestinal diseases by the appearance of the 
stools. Muco-sanguineous stools accompanied 
by fever are a sign of colitis. Stools contain- 
ing unmixed blood and not accompanied by fever may result from a rectal 
polypus and from purpura h^emorrhagica. Scanty evacuations of blood, with 
obstinate constipation, are a symptom of intussusception in infants. 



Fig. 4. 




94 DIAGNOSIS OF INFANTILE DISEASES. 

The alvine discharges of infants often present a green color ; sometimes 
they have the normal yellow hue when passed from the bowels, but become 
green on exposure to the air or from reaction of the urine. By the microscope 
the green coloring matter is seen to occur in small, irregular masses. This 
green substance has been supposed to be bile. I am convinced that as it 
occurs in the stools of the infant it is commonly produced by the action of the 
intestinal secretions on the contents of the intestines ; for I have often noticed 
that the contents in and above the jejunum were yellow, while in and below 
the ileum their color was green. Probably the green color is due to the for- 
mation of biliverdin from the bile which is mixed with the fecal matter. 

The green hue may occur from very different causes. It may be due to over- 
feeding, to the action of cold, to irritating ingesta, to inflammation, etc. ; it 
may be transient, subsiding within a day or two, or it may continue several 
days. All infants at times have green evacuations, even when they appear 
in good health. 

In the commencement of a large proportion of diarrhoeal maladies in 
infancy the stools give an acid reaction to litmus-paper. This acid, if in 
considerable quantity, is irritating, increasing the peristaltic movements of 
the intestines and the functional activity of the intestinal follicles, causing 
erythema of the skin around the anus, and reacting upon and intensifying 
the intestinal disease. Hence the indication for the use of antacids in the 
diarrhoeal affections of infancy. 

The presence of intestinal worms and the species may be ascertained by 
microscopic examination of the stools of a child which is affected with these 
entozoa. The stools contain ova, which differ in size and shape according to 
the species of worm. 



Nervous System. 

Pain. — This symptom affords important aid to the physician in determin- 
ing the seat and nature of the diseases of children. Pain in the head may 
occur in them from coryza involving the frontal sinuses, or from febrile 
movement in the commencement of an essential fever, or from inflammation 
of one of the organs of the trunk. Produced by such a cause, it abates in 
two or three days. If it be protracted, whether constant or intermittent, it 
is in many cases not neuralgic,' as it so often is in the adult, but is due to 
organic disease of the brain or meninges. Complaint, therefore, of head- 
ache in a child, without any apparent general cause or local cause external 
to the cranium, should awaken solicitude, and if it be protracted the physi- 
cian should examine carefully in reference to the presence of a cerebral or 
meningeal disease. Mild frontal headache continuing for weeks or months is 
neuralgic and due to anaemia. It is increased by pressure over the occiput 
and upper cervical vertebrae. 

Grave thoracic or abdominal inflammations in the adult are almost always 
attended by a corresponding amount of pain and tenderness, but in children 
these symptoms are often absent, or when present are frequently not commen- 
surate with the amount of disease. Thus, entero-colitis of nursing infants is, 
in a large proportion of instances, almost free from these symptoms. 

Pain in the chest or abdomen, occasional or constant, continuing for weeks 
or months, with fever, and unattended by thoracic or abdominal disease, indi- 
cates caries of the vertebrae. Its most common seat is the epigastric, umbil- 
ical, or hypochondriac region. It is a neuralgia due to irritation of the 
sensitive root of one or more of the spinal nerves. It is a very important 
symptom to the diagnostician, showing the nature of the disease, which in its 



THERAPEUTICS. 95 

incipiency is so obscure. Pain in the leg, especially the inside of the knee, 
is of a similar character, indicating disease of the hip-joint. 

Children with certain acute febrile and inflammatory diseases sometimes 
have hyperaesthesia of portions of the surface ; it is especially marked upon 
the anterior aspect of the trunk. The physician might be misled into the 
belief that the tenderness occurred over the seat of the disease and indicated 
an inflammation ; but the pain of hyperaesthesia can be diagnosticated from 
that of inflammation by fche fact that it is so extensive, is less on firm than 
light pressure, and is especially observed upon the inner surface of the thighs. 
The symptoms pertaining to the nervous system occurring in the various dis- 
eases treated of in this book will be fully described in connection with those 
diseases, and therefore need not detain us in this connection. 



CHAPTER XI. 
THEEAPEUTICS. 

The young practitioner is often perplexed in deciding exactly what dose 
of the stronger and more dangerous medicinal agents to prescribe for a child. 
A practical rule, which holds good for many medicines, has been proposed by 
Dr. Cowling, as follows : " The proportional dose for any age under adult life 
is represented by the number of the following birthday divided by twenty- 
four." This rule is inadmissible for infants under the age of six months, but 
will apply for those that are older for the use of a large number of medicines. 
Another rule, proposed by another British physician, Professor Clarke, is based 
on difi"erences in weight of children and adults : The adult dose is represented 
by 150. The dose of a child is determined by dividing its weight in pounds 
by 150. But it is an interesting fact, and one of practical importance, that 
children bear and often require, in order to obtain the desired effect, a much 
larger proportionate dose of certain agents than adults. This is partly attrib- 
utable to the active elimination in childhood. Belladonna is notably one of 
the agents which children tolerate, and it may be added that some children 
can take a much larger dose of it than others without producing the physio- 
logical efi"ects. Thus, recently I increased gradually the tincture of bella- 
donna to twelve drops for a child of four years without producing the usual 
efflorescence ; and Farquharson says " the dose .... I have pushed in a 
child of ten suffering from incontinence of urine to fgij (British Pharmacop.) 
with good eff"ect and the development of mild forms of physiological disturb- 
ance." Arsenic is also better tolerated by children than adults. An infant 
of six months can take two-drop doses of Fowler's solution three times daily 
without ill effect. Prussic acid, strychnia, iron, ipecacuanha, and alcohol are 
also required in larger proportionate doses in childhood than is indicated by 
the rule either of Dr. Cowling or Professor Clarke. 

When practicable, medicines should be given in the liquid form. Those 
not soluble may often be given in suspension in some vehicle which in great 
part disguises the taste. A good vehicle for the bitter vegetables, as the salts 
of quinia, is the elixir adjuvans of Caswell and Hazard. 

The elixir adjuvans may also be advantageously employed in the adminis- 
tration of many other medicines apart from those which are repulsive on 
account of their bitterness. It holds them in suspension, so that if they have 
a greater specific gravity than the elixir, it is necessary to shake the bottle 



96 THERAPEUTICS. 

thoroughly before using it. The elixir taraxaci comp. is another good vehi- 
cle for the bitter vegetables, but perhaps their bitterness, especially that of 
quinine, is more effectually disguised by the syr. yerbae santae comp. than 
by any other vehicle. I am sure, from many observations, that unpleasant 
doses are liable to be wasted to a greater or less extent, and the repug- 
nance of children to medicines employed has induced many a parent to seek 
other and less disagreeable modes of treatment. Chemistry has greatly aided 
the therapeutics of childhood, in that it has enabled us in so many instances 
to prescribe the active principles in place of the large, nauseous doses formerly 
employed. 



PART II 



DISEASES OF THE NEWLY-BOKN. 



CHAPTER I. 

MALFOKMATIONS. 

Asphyxia, or apnoea neonatorum, is tlie first in time in the long cata- 
logue of human maladies. It requires and receives the immediate attention 
of the accoucheur, and is treated of fully in books relating to midwifery. 
We -will therefore omit the consideration of it from our remarks on diseases 
of the newly-born. We will also postpone our remarks on diphtheria of the 
newly-born until we treat of diphtheria in full. 

The malformations, both of internal and external organs, are numerous, 
and they require attention according to their seat and gravity. We will 
describe only such as are of especial interest to the physician. 



Fig. 5. 



AcRANIA. 

In this malformation the bones and integuments forming the cranial arch 
are absent. In extreme cases the cranial arch, part of the neck, the brain, 
and the medulla oblongata are lacking. A 
vascular mass lies on the exposed base of 
the skull, often resembling the placenta in 
appearance. It consists of connective tis- 
sue in addition to the vessels. It is the 
representative of the cerebral meninges, 
and is continuous below with the spinal 
meninges. Its smooth surface is the ana- 
logue of the arachnoid. The sensation which 
is imparted to the finger of the accoucheur 
pressed upon it is very similar to that pro- 
duced by a placenta. In some specimens 
small portions of cerebral matter are found 
among the vessels of this tumor, but they 
are so disconnected and isolated that they 
do not perform in any way the functions of 

a brain. Occasionally the vascular tumor is absent and the medulla — or, if 
this be absent, the upper extremity of the spine — is exposed. 

The absence of the brain and cranial arch gives a remarkable appearance. 




98 MALFORMATIONS. 

The frontal, parietal, and occipital bones are absent, except those portions 
which are near the base of the cranium. These portions are very thick and 
closely united, as if there were the usual amount of osseous substance, but 
instead of expanding into the arch it had collected in an irregular mass at 
the base of the cranium. The eyes are prominent, the neck thick and short, 
while the body and limbs are ordinarily well developed. The physiognomy 
has a frog-like appearance. Those portions of the cranial nerves which lie 
without the cranium are well developed, although the intracranial portions 
are absent. In this anomaly of acrania and anencephalus a twin is often 
present which in some manner has interfered with the normal development 
of the foetus. 

Symptoms. — If the medulla be absent, of course viability is impossible. 
If it be present, respiration may occur for a time, but is irregular. The 
monster may be made to cry, but the cry is a reflex phenomenon resembling 
a sob or hiccough. It may nurse, its digestive function is well performed, 
and regular urinary and fecal evacuations occur. There is a tendency in such 
monsters to convulsions. Blowing upon them and pressure upon the project- 
ing medulla, if this be present, frequently produce this result. 

Prognosis. — Fortunately, non-viability or speedy death is the result. If 
the medulla be present and respiration and circulation be established, never- 
theless death usually results within two or three days, and with scarcely an 
exception within ten days. Convulsions sooner or later supervene, ending in 
fatal coma. 

Incomplete Brain. 

Deficiencies occur in the formation of the brain, so that there are various 
grades of incompleteness between the normal and absent brain. Portions of 
the brain may be absent or rudimentary, while the remainder of the organ 
has its normal development. The deficiencies are usually in the cerebral 
hemispheres, while the base of the brain, which is important for the main- 
tenance of life, is perfect. Both hemispheres may be absent, or one absent 
while the other is complete or small and rudimentary. Incompleteness of the 
brain may be manifested by the small size of the cranium and the retreating 
forehead, but occasionally the cranium has its normal shape and size, on 
account of an increase in the cerebro-spinal fluid proportionate to the defi- 
ciency in the cerebral development. Such a case was under observation in 
the Nursery and Child's Hospital in 1862. She took the breast and received 
food when placed in her mouth, but without apparent relish. She was sup- 
posed for a time to be blind, as she was apparently unconscious of objects 
around her. There was a total absence of intellectual manifestations. The 
size and shape of the head did not diff"er materially from the normal, but the 
frontal bone lay a little lower than the parietal. She died of entero-colitis at 
the age of ten months, and at the autopsy a sac containing about three-fourths 
of a pint of nearly transparent cerebro-spinal liquid occupied the site of the 
cerebral hemispheres. Rudimentary hemispheres were found constituting a 
part of the walls of the sac. The weight of the brain after being a few days 
in dilute alcohol was 61 ounces. In this case the fluid was nearly sufl&cient 
to compensate for the lack of brain-substance. 

Symptoms. — Since in cases of imperfect brain in which life is preserved 
the arrest of development is usually in the cerebral hemispheres, the symp- 
toms which indicate the deficiency relate chiefly to the degree of mental 
endowment. If the hemispheres are partially developed, there is a degree 
of intelligence proportionate to the amount of the cerebral substance present. 
If the arrest of development be on one side, there may be no appreciable lack 



MENINGOCELE, ENCEPHALOCELE, HYDRENCEPHALOCELE. 99 

of intelligence or mental activity, since one hemisphere may perform the func- 
tions of both. 

Prognosis. — This as regards life depends on the seat of the arrested 
development. If the cerebral hemispheres be deficient, the child may live 
and thrive, though idiotic ; but if the arrest of development be at the base 
of the brain, which controls the functions of animal life and gives origin to 
nerves which are essential to the physical well-being, life is uncertain and 
probably will be short. It is evident that therapeutic measures cannot 
remedy a congenital deficiency in the brain, but the patient, philanthropic 
teacher can impart some instruction to the idiotic, and occasionally improve 
in a measure their lamentable condition. 

Meningocele, Encephalocele, Hydrencephalocele. 

This is the analogue of spina bifida. An opening exists at some point in 
the skull, through which the meninges, or meninges with brain-substance, 
protrude. The deficiency is congenital, and the tumor exists at birth or is 
noticed soon after. It is termed a meningocele if only meninges protrude ; 
an encephalocele if it contain brain-substance in addition to the meninges ; 
and a hydrencephalocele if, in addition to the brain-substance, the mass con- 
tain liquid in its interior. 

The most frequent site of these tumors is the occiput, where the protru- 
sion occurs from an opening in or at the edge of the occipital bone. The 
next most frequent location is the naso-frontal region. Rarely they occur 
upon the temporal, parietal, and basilar portions of the skull. Ordinarily, 
the opening in the occipital bone through which the protrusion takes place is 
at the median line, or near it. anterior or posterior to the occipital protuber- 
ance. The opening, if in the anterior part of the occipital bone, may extend 
to the fontanel : if in the posterior part, it may extend to the foramen mag- 
num. It may connect posteriorly through the foramen magnum with the 
cleft of a spina bifida. If the opening in the occipital bone be large, the 




tumor is also usually large. Prescott Hewitt cites a case in which it extended 
to the loins ; but so large a mass consists mostly of liquid and is rare. An 
occipital encephalocele contains brain-substance from the cerebellum or pos- 
terior cerebral lobes or from both. If the tumor upon the occiput be a 
hydrencephalocele, the liquid is from the posterior cornu of a distended 



100 MALFORMATIONS. 

lateral ventricle or from a distended and dropsical fourth ventricle, and it 
occupies the interior of the tumor, the brain-substance surrounding it. 

If the tumor be in the frontal region, the protrusion usually occurs 
between the cribriform plate of the ethmoid bone and the frontal bone, and 
it appears externally between the nasal and the frontal bones. Exception- 
ally, the point of protrusion is between the lateral halves of the frontal bone. 
The anterior lobe or lobes of the cerebrum protrude in an eneephalocele in 
this location ; if the tumor be a hydrencephaloeele, the liquid is derived from 
the anterior cornua of the lateral ventricles. As a rule the frontal are smaller 
than the occipital tumors, and the skin covering them is more frequently red 
and vascular, so as to present the appearance of vascular tumors. 

Exceptionally, the protrusion occurs from a fontanel or from the line 
of one of the sutures, so that it is seated upon the side of the skull. Cases 
are also on record in which the opening existed between the ethmoid and 
sphenoid bones, through the sphenoid, or between the sphenoid and its greater 
wing. Tumors in this location appear in the pharynx or mouth, or enter an 
orbit, displacing the eye, or protrude through the spheno-maxillary fissure. 
The tumor having this site is usually an eneephalocele or hydrencephaloeele, 
the meningocele being rare. Its walls consist of skin, dura mater, and 
arachnoid, with intervening connective tissue. If the protrusion be at the 
base of the brain, of course the external covering of skin is lacking. In 
other locations the skin constitutes the external coat, and it may be tense and 
scantily covered with hair, or red and vascular. The interior of the sac is 
lined by the arachnoid and dura mater. These tumors, whatever the exact 
character of their interior, can be more or less reduced by compression, with 
a return of a part of their contents into the cranial cavity ; but such com- 
pression usually produces cerebral symptoms, as stupor or fretfulness, vomit- 
ing, and strabismus. The following characteristics of the three forms of these 
tumors aid in their differential diagnosis: 

Meningocele. — Small at first, and remaining either small or of moderate 
size, fluctuation distinct, pedunculated, translucent, no pulsation, tense on 
forced expiration, reducible. 

Eneephalocele. — Small, base wide, no fluctuation, opaque, or some- 
times translucent at the apex, distinct pulsation, enlargement by forced expi- 
ration, partly reducible, cerebral symptoms occurring from compression, 

Hydrencephaloeele. — Tumor usually large, often pendulous, and its 
surface lobulated, pedunculated, fluctuating ; portions translucent ; pulsation 
absent or rare. It is seldom affected by pressure, and the patient is likely to 
be microcephalic from the escape of brain-substance external to the cranium. 

These protrusions have been mistaken for various cysts, as cephalaema- 
toma, serous and sebaceous cysts, abscesses, vascular growths, and polypi. 
The fact that such errors in diagnosis have been made by various surgeons 
shows the importance of a thorough and careful examination before operative 
measures are employed. 

Most patients with this deformity die in a few weeks or months. The 
prognosis depends on the size of the aperture and the amount of protrusion. 
It is most unfavorable in hydrencephaloeele, which is usually attended by 
deficiency of brain within the cranium, sometimes to such an extent that the 
patient is microcephalic and early death unavoidable. The hydrencephalic 
tumor is very liable to grow, and, after a time, rupture, causing immediate 
death in convulsions or collapse. In meningocele, if the aperture be small, 
the tumor may remain small, become isolated from the cranial cavity, and 
the patient may live for years. But of the three forms of the tumor, eneeph- 
alocele is regarded as the most favorable, since it is usually small, and 
patients with it not infrequently live many years. The prognosis in these 



SPINA BIFIDA. 



101 



tumors is very similar to that in spina bifida, which varies according to size 
of the aperture and the amount and character of the protrusion. 

Treatment. — Those who have had experience with these tumors concur 
for the most part in the opinion that surgical interference should not be 
resorted to unless rupture be imminent. The mass should be protected from 
abrasion, and that degree of pressure should be employed which can be toler- 
ated without producing cerebral symptoms. It is proper to draw off the 
liquid of a meningocele if it be distended and likely to rupture, and the tap- 
ping may be repeated, with, exceptionally, the result of a cure or of render- 
ing the tumor stationary. Mr. Holmes has injected the tumor with two 
drachms of a mixture consisting of one part of tincture of iodine and two 
of water, allowing it to remain : and Mr, Annandale has ligatured the mass 
in one instance, and effected a cure. In encephalocele and hydrencephalocele 
support and moderate pressure should be employed, and in the latter some 
of the liquid should be removed by a small trocar if rupture be threatening. 



Spina Bifida. 

This is one of the most common of the malformations. In its severe 
form it is from its nature incurable, admitting only of palliative treatment, 
while in its milder forms it may be cured or so relieved that it does not 
endanger life. The term spina bifida is applied to a hernia of the spinal 
meninges, which produces a rounded tumor, situated posteriorly over the 
spine in the median line. It is due to the congenital absence or incomplete- 
ness of one or more of the arches of the vertebras. In exceptional instances 
the arch is said to be complete at birth ; but the lateral portions separate and 
are pressed outward during the first weeks of life. The tumor contains cere- 
bro-spinal fluid, and unless it be small and its walls unusually thick fluc- 
tuation may be detected in it. When the child cries the tumor enlarges, and 
it is reduced by compression, the fluid re-entering the spinal canal. If the 
tumor be large, its complete subsi- 
dence by pressure often produces Fig. 7. 
dangerous cerebral symptoms. Spina 
bifida is the analogue of hydro- 
cephalus, and the two often coexist. 
If we compress the hydrocephalic 
head the spinal tumor enlarges, and 
vice versa. Club-foot is another not 
infrequent complication. In the 
case which is represented in the 
accompanying wood-cut (Fig. 7), 
hydrocephalus, spina bifida, and 
club-foot coexisted. The child was 
brought to the children's class in 
the Out-door Department at Belle- 
vue, and after a few visits I lost 
sight of it. It probably died soon 
after, since the tumor, over which 
the cuticle was wanting, presented 

a deep red appearance as if inflamed, so that ulceration and escape of the 
fluid seemed near at hand. There is ordinarily but one spina bifida, the com- 
mon seat of which is the lumbar region, but occasionally two or more are 
present. If the aperture through which the tumor protrudes be small, it is 
usually pedunculated, but if large it is sessile. In some patients it is cov- 
ered with skin, which may be normal or somewhat indurated ; in others the 




102 MA LFORMA TIONS. 

skin is absent over the entire tumor or its most prominent part, and the dura 
mater or the connective tissue lying directly over the dura mater is exposed, 
and is liable to inflammation from friction. If the walls of the tumor be 
thin, the liquid may transude in drops, and they are liable to give way by 
ulceration or rupture. Sudden escape of the liquid and collapse of the spina 
bifida involve great danger, for convulsions, coma, and death are the common 
result. 

The relation of the spinal cord or nerves, or of the cauda equina, to the 
tumor is a matter of great importance. In many patients the adjacent por- 
tion of the cord or cauda equina is deflected through the aperture, and lies 
against the anterior of the sac. Spinal nerves also not infrequently lie within 
the sac, some returning into the spinal canal, and others passing through the 
walls of the sac to their points of distribution. Those which are deflected 
into the tumor and return into the canal obviously lie lowest. In the most 
favorable cases — to wit, those with a small aperture or small tumor or a nar- 
row and long peduncle — neither the cord, cauda equina, nor nerves lie within 
the sac. It is important to the practitioner to bear in mind that in all prob- 
ability, unless under the favorable anatomical circumstances stated above, the 
sac contains nervous elements. In rare instances the liquid, instead of lying 
externally to the cord, lies within its central canal. The substance of the 
cord then becomes distended, and it encloses the liquid like a delicate sac, 
just as the hemispheres of the brain are unfolded and expanded in the com- 
mon form of congenital hydrocephalus. As might be expected from the 
anatomical characters of the more serious forms of spina bifida, paralysis, 
more or less complete, of the vesical and rectal muscular fibres and par- 
aplegia sometimes occur, in which event the fatal issue is probably not far 
distant. 

Diagnosis. — This is easy in ordinary cases. The congenital nature of 
the tumor and the bony edge of the aperture, appreciable to the touch, suffice 
in ordinary cases to establish the diagnosis. The diminution of the tumor 
by pressure, and its enlargement when the child cries, are important diag- 
nostic signs. There are various lumbo-sacral tumors located in the median 
line from which it is important that spina bifida should be diagnosticated. 
Sometimes a cyst occurs in this situation which was originally a spina bifida, 
but obliteration of the canal in the pedicle occurred, just as the canal con- 
necting a hydrocele with the abdominal cavity closes. Solid congenital 
tumors sometimes also grow in the same situation, among which, as most 
common, may be mentioned fatty tumors and tumors containing foetal remains. 
The most common seat of tumors which enclose foetal remains is at the point 
where spina bifida ordinarily occurs. Physicians have erred in mistaking 
these tumors, as well as those which consist of fat, for spina bifida ; but a 
mistake in diagnosis can only occur through haste or carelessness of exami- 
nation. 

Prognosis. — This is in most instances unfavorable. Ordinarily the tumor 
increases slowly, and finally the sac gives way by ulceration or rupture ; the 
liquid escapes, and death occurs in convulsions and coma; or, if the escape 
of the liquid be prevented by pressure and the aperture closes, a second rup- 
ture is probable, with a fatal result. In other cases the tumor may not rup- 
ture, but the cord is softened or it is injured by being bent, so that paraplegia 
results, and death after a time occurs in a state of emaciation. Rarely the 
tumor may shrivel by absorption of the liquid, and the disease is cured, or 
so nearly cured that it gives no inconvenience and the patient lives for years. 
In other rare instances the tumor may remain without any material change 
and without giving rise to symptoms. The spina bifida being small and cov- 
ered with skin, and the aperture leading from it into the spinal canal being 



SPINA BIFIDA. 103 

also small, the patient lives through the natural period of life with little 
inconvenience. 

Treatment. — It is evident, from what has been stated, that no fixed 
rule can be laid down for the treatment of spina bifida. In the most favor- 
able cases, in which no symptoms occur and there is no indication that 
the tumor will undergo any unfavorable change, surgical treatment is not 
required, except the application of a soft pad to support the tumor, so as to 
prevent its injury by friction. Indications which justify active surgical inter- 
ference are growth of tumor, absence of skin from it, with tension of the 
parietes, so that an early rupture is inevitable, and the occurrence of dan- 
gerous nervous symptoms, as convulsions or paraplegia. 

From the nature of spina bifida it is evident that operations upon it must 
be conducted with caution. The usual presence of the spinal cord in the 
pedicle and in the sac forbids ligation and excision, and renders hazardous 
attempts to obliterate the sac by producing inflammation within it. A safe 
mode of treatment, but not the most efiicient, is to puncture the sac and 
withdraw a portion of the liquid by a grooved needle or hypodermic syringe. 
A soft pad should then be applied to produce gentle compression. If no 
unfavorable symptoms occur, the puncture may be repeated after a day or 
two. This operation has been employed with a satisfactory result by Sir 
Astley Cooper among others ; but, simple as it is, it is not devoid of danger, 
for the removal of the liquid, if carried beyond a certain point, may produce 
dangerous nervous symptoms, especially convulsions. In performing the 
operation the puncture should never be made in the median line, on account 
of the danger of wounding the cord, which lies against the median portion 
of the sac. The veins, also, should be avoided. 

Another mode of treatment is by iodine injections. They are preferable 
to other methods if the neck be long and pedunculated, so as to be easily 
compressed. If the tumor be sessile, and the aperture into the spinal canal 
be free, these injections involve great danger, and are not to be recommended; 
for more or less of the solution will inevitably enter the spinal canal and 
give rise to spinal meningitis. Iodine injections have been employed with 
success by Professor Brainard of Chicago, who slates that he " perfectly and 
permanently cured " three of seven cases ; and by Velpeau of Paris, by 
whose method five in ten operations were successful, and by many others. 
Professor Brainard withdrew some of the liquid contents, and then injected 
half an ounce of water containing 22- grains of iodine and 7 J grains of iodide 
of potassium. In a few seconds this was allowed to flow out, and the sac 
was then washed out with tepid water. Then a portion of the cerebro-spinal 
fluid, which had been kept warm, was returned into the sac. When he had 
withdrawn six ounces of this fluid he returned two ounces. In employing 
the iodine or any other irritating injection, it is necessary to compress the 
pedicle, so that the liquid does not enter the spinal canal. Velpeau employed 
one part of iodine, one of iodide of potassium, and ten of distilled water. 

During a debate in the Societe de Chirurgie, M. Debont recommended 
the evacuation of only a little of the fluid, and the injection of two or three 
drops of the tincture of iodine diluted with an equal quantity of water. T. 
Smith,^ by the injection of one drop of the tincture, produced an amount 
of inflammation which nearly obliterated the sac. Since statistics show so 
good a result of iodine injections, this mode of treatment seems preferable 
to any other for certain cases, and as one drop has produced general inflam- 
mation of the sac and nearly obliterated it, it seems safest and best to begin 
with so small a quantity. 

If there be reason to believe, from the small size of the orifice and other 

^ Holmes's Surg. Dis. of Children. 



104 MALFORMATIONS. 

anatomical characters, that neither the cord, cauda equina, nor any of the 
spinal nerves lie within the sac, it may be thought best to remove the tumor. 
It has, indeed, been proposed to open the tumor, immersed under warm water, 
sufficiently to observe the relation of the nervous elements, and to press them 
back gently into the canal if they lie within the sac. If it be decided to 
remove the spina bifida, a clamp or elastic band is placed around the pedicle 
so snugly as to cause firm adhesion of the walls of the pedicle, and excite 
sufficient inflammation in them to produce agglutination, but without causing 
strangulation or suppuration. 

After a time, perhaps two or three days, when it is evident that agglutina- 
tion has occurred from the fact that the liquid cannot be returned within the 
spinal canal by compressing the sac, the tumor may be removed by the knife 
or ecraseur. Statistics do not show so favorable a result of this operation as 
of the iodine treatment, and the reason is obvious, for it is only in excep- 
tional cases that the tumor can be removed without injury to the nervous 
tissue, and incision of a portion of the cord or of important nerves either 
produces death or a condition to which death would be a relief. 

Spina bifida has also been treated by opening the sac on its side, pressing 
back the spinal cord or its nerves into the spinal canal, uniting the edges of 
the wound, and then applying pressure to prevent protrusion, but the result 
has not been favorable. Treatment by simple puncture, followed by com- 
pression, and if it fail, as it probably will, the cautious use of iodine injec- 
tions, is the preferable mode of treating ordinary cases of spina bifida which 
require surgical interference. 

Congenital Abnormalities in the Circulatory System. 

Rarely the position of the heart is abnormal, and the most common mal- 
position is its location on the right side of the chest (dextro-cardia). This 
occurs with or without misplacement of other organs. In cases of dextro- 
cardia the liver usually, says Niemeyer, occupies the left hypochondrium, 
and the spleen the right. In this misplacement of the heart the aorta ordi- 
narily crosses the right bronchus and passes along the right side of the ver- 
tebras, but occasionally it crosses the spine and lies in its usual position on 
the left side of the vertebrae. The heart in this malposition is sometimes 
imperfect and sometimes well formed. In mesocardia the heart is situated 
nearer the median line than usual, corresponding in this respect with the 
position which it occupies in the first months of foetal life. A rare malposi- 
tion is the location of the heart outside the thoracic cavity (ectocardia extra- 
thoracica) — a condition accompanied by, and perhaps due to, deficiency in 
the sternum or sternum and ribs. In other instances equally rare a part 
of the diaphragm has been deficient, and the heart has lain in the abdomen ; 
and in other instances still it has been located at the base of the neck. 
Breschct and others have cited examples of these various forms of ectopia 
cordis. 

Symptoms — Prognosis. — If the heart be well formed and complete, its 
abnormal position within the thorax may not give rise to symptoms, and is 
not incompatible with prolonged life. If it be located without the thoracic 
cavity or be within the cavity and be defective, early death is probable. 

Malformations of the Heart. 

Malformation of the heart occurs — 1st, from arrested development early 
in foetal life, so that the organ remains rudimentary ; 2d, from arrested 
development at a more advanced stage, when the cavities, septa, and ves- 



MALFORMATIONS OF THE HEART. 105 

sels, though incomplete, are partially formed ; 3d, from malposition of the 
parts of the heart or of the vessels in immediate relation with the heart. 
The cause of malformation in the heart and the vessels pertaining to it is 
obscure. It is supposed sometimes to be a myocarditis or endocarditis, which 
causes the arrest of growth or abnormal development. 

Perhaps strong mental excitement sometimes has a causal relation, what- 
ever may be its modus operandi, just as it causes external malformations. 
In a case related by Dr. Peacock ^ the mother stated that when pregnant she 
was greatly frightened by the appearance of a man who was dying of asthma. 
In another instance the only assignable cause was fright of the mother at 
seeing a child killed, and she did not recover from the shock ;"' in another 
case the mother was greatly alarmed at the fifth month of gestation,^ and in 
the fourth instance the mother four or five months before her confinement 
was greatly frightened by her husband, who was insane, standing over her 
two hours with a loaded pistol.^ But these are exceptional instances. In a 
large majority of cases of malformation of the heart inquiry fails to elicit any 
unusual mental excitement of the mothers during their gestation. 

Occasionally the malformation appears to be due to some vice or taint in 
the system of one or both parents. Thus in a case quoted in the Gazette 
medicah for Dec. 28, 1850, the mother, who had rachitis in early life, lost 
five children soon after their birth, all of whom had lividity as the most promi- 
nent symptom. Persistent lividity in the newly-born indicates, almost with- 
out exception, malformation at the centre of circulation. In the history of 
a case which was communicated to Cooper by Farre " vices of conformation 
of the heart appear to have been inherent in the family. Of 12 infants only 
-1 survived,'' the death of the 8 being apparently from cardiac malformation. 
A patient treated by Mr. Leonard was the sixth who had died at about the 
same age with symptoms of cyanosis. Ordinarily, however, infants who have 
cardiac malformations, as indicated by the cyanotic hue, belong to healthy 
families; neither parents, brothers, nor sisters exhibit any taint of system 
which could sustain a causal relation to any form of malformation. 

The opinion is expressed by Gintrac that the number afi'ected with car- 
diac malformation, as indicated by cyanosis, to the entire population varies 
in different countries. It is probable that its occurrence is not greatly, if at 
all, afi"ected by the nationality, but it is certainly dependent to a considerable 
extent on the condition of society. It appears from statistics to be less fre- 
quent in a community in comfortable circumstances and engaged in quiet and 
wholesome occupations than in those whose occupations produce undue 
mental excitement and worriment and irregularities in the mode of life. 
Pure air and outdoor exercise, plain, nutritious diet, freedom from cares and 
anxieties — in fine, causes which promote the physical well-being — diminish 
the liability to a malformed and cyanotic oiFspring ; and, on the other hand, 
impure air, improper and insufficient diet, grief, etc. increase the percentage 
of cardiac malformations, and cyanosis. Hence the blue disease is rare in 
the rural districts and comparatively frequent in the cities, especially in a 
large city like New York, which contains a numerous indigent and careworn 
population, living from year to year in the midst of agencies which operate 
stealthily but certainly to enervate the system and undermine the health. 

These remarks are abundantly substantiated by statistics. In New York 
City, during the period of six years, 1 death resulted from cyanosis to 436 
deaths from all causes, and in Brooklyn the proportion estimated for two 
years was about the same. On the other hand, in the State of Kentucky, 
which contains few large cities, there was, during a period of five years, 1 

^ Malformations of the Heart, p. 57. ^ Ibid., p. 87. 

Ubid.,-p.^\. ^Ibid.,p.4S. 



106 MALFORMATIONS. 

death from malformation of the heart to 2469 from all causes. In the State 
of South Carolina, for three years, 1 death resulted from cyanosis to 5018 
from all causes. In the State of Massachusetts, for two years, there was 1 
death from cyanosis to 1136 from all causes, and two-thirds of the cyanotic 
cases occurred in the counties of Suffolk, Essex, and Worcester, which con- 
tain large cities, In London 1 death occurred from cyanosis to 755 from all 
causes during a period of three years. On the other hand, in England, 
including the city of London, there was, for the' ten years ending with 1857, 
1 death from cyanosis to 1589 from all causes; and in the rural districts of 
Monmouth and Wales only 1 death occurred from cyanosis to 5578 deaths 
from all causes during a period of two years. 

Malformations of the heart derive their seriousness and importance from 
the fact that the heart is the central organ of circulation, so that when from 
malformation it is inadequate to perform fully its function, not only is the 
nutrition seriously interfered with, but the flow of blood through the lungs 
is insufficient. The blood is not properly oxygenated, and it is overcharged 
with carbonic acid, which imparts to it the deeply venous or livid color. 
Cyanosis therefore, as indicative of an imperfect heart, a persistent defect 
in the circulation, and a permanently abnormal state of the blood, is an 
important disease. 

Cyanosis. 

As stated above, the cause of cyanosis when occurring in infants is at 
the centre of circulation, and is a malformation with very few exceptions. 
The diagnosis can be made with certainty if there have been no symptoms 
indicating an antecedent disease. In rare instances in infants above the age 
of five or six months lividity of the surface occurs from disease in the lungs, 
such as extensive emphysema, a pleuritic exudation compressing both lungs, 
caries of the vertebrae, with consequent depression of the ribs so as to pre- 
vent proper inflation of the lungs. But such causes do not exist or are very 
rare under the age of six months. 

The blue disease, being so manifest, attracted attention at an early age. 
It appears from the remarks of Boerhaave that the common people believed 
that the cyanotic were possessed by evil spirits.^ It was evidently impos- 
sible to understand its cause and nature prior to the discovery of Harvey in 
the seventeenth century, and most of the exact or scientific knowledge pos- 
sessed by the profession in reference to the etiology and nature of cyanosis 
has been achieved since the present century commenced. Boerhaave and 
Vieussens had observed cases and propounded theories in reference to it, but 
the knowledge of physicians concerning it remained vague and indefinite. 
No better idea can be given of the prevailing ignorance in reference to cya- 
nosis, even after the present century commenced, than by quoting from a case 
related by Kibes in 1814.^ The patient had some time previously received 
an injury of the finger. " Many physicians of Amsterdam," says he, '' were 
at dilferent times consulted on the subject of this affection, no one of whom 
understood its true cause, its essential character. One considered it as par- 
taking of the nature of epilepsy, and caused by the irritation in the nervous 
system which the wound in the finger had produced. Others attributed it to 
the presence of intestinal worms. Some physicians pronounced it an injury 
to the liver or spleen. Many held it to be a scorbutic affection. One only 
believed it to be the result of an unknown organic disease." In the present 
century numerous carefully observed cases of cyanosis published in the 
medical journals, and the writings of Seller, Louis, Bouillaud, Farre, Chev- 

^ Diseases of the Humors. ^ Bull, de la Fac. de 3Ied., 1815. 



CYANOSIS. 107 

ers, Peacock, Marston, Stille, and others, have contributed to a better under- 
standing of the nature and anatomical characters of cyanosis. 

Sex. — Whatever may be the explanation, the following statistics show ah 
excess of male infants affected with cyanosis : 



les. 



Table 1. 
180 cases collated by Aberle .... two-thirds mal( 

44 " " " Gintrac .... 28 males, 16 females. 

41 " " " Stille 21 " 10 '• 

134 " " " J. Lewis Smith . 78 " 56 " 

Table 2. — Deaths from Cyanosis. 

Males. Females. 

In London, England, in two years .... 418 273 

In New York City, in five years 117 90 

Time of Commencement. — It is an interesting and somewhat remark- 
able fact that cyanosis, though dependent on a malformation, does not always 
commence at birth, or at least does not exist in degree sufficient to produce 
the cyanotic hue till some time has elapsed after birth. In 138 of the cases 
of cyanosis w^hich I have collected the time at which lividity was first observed 
is stated as follows : In 97 it was wdthin the first week, and generally within 
a few hours of birth. In the remaining 41 cases it commenced as follows : 

In 3 at 2 w^eeks. In 6 from 2 vears to 5 years. 

" 1 " 3 " " 1 " 5 ' " " 10 " 

" 2 " 1 month. " 6 '' 10 " '"20 " 

" 7 from 1 to 2 months. " 1 " 20 " " 40 " 

" 5 " 2 " 6 " i " 1 over 40 vears. 

a 5 a Q a;j2 " 



3 " 1 year to 2 years, i 



41, total. 



In these 41 cases, in which blueness did not occur till after the age of one 
week, if the patient were less than two years old when it commenced there 
was frequently no obvious exciting cause, but above this age, with three 
exceptions, such a cause is known to have been present. It is interesting to 
observe how trivial the exciting cause frequently is, and equally interesting 
to note how long patients have enjoyed good health, not having the least 
lividity, although the anatomical vice to which the final development of 
cyanosis was due had existed from birth. 

Dr. Theophilus Thompson relates^ the history of a lady, thirty-eight years 
old, who was well till an attack of Asiatic cholera, after which her health 
was permanently impaired. Two years before her death she passed through a 
course of fever, and from this time was cyanotic. In the Philadelphia Med- 
ical Examiner, June, 1850, Dr. Waters relates a case in which cyanosis began 
at the age of six years in an attack of measles. In a case published by Mr. 
Napper in the London Medical Gazette, 1841, the child fell at the age of six 
months, and from this time had cyanosis. A female whose history is given 
by Prof. Tommasini of Bologna, and quoted by Bouillaud, became cyanotic 
at the age of twenty-five in consequence of difficult parturition, In the Lon- 
don Lancet, 1842, Mr. Stedman relates a case in which cyanosis began at the 
age of ten weeks in an attack of convulsions. In the American Journal of 
Medical Sciences, in 1847, Dr. John P. Harrison published the history of a 
haker, twenty years old, in whom cyanosis began five years previously after 
great effort in carrying wood. Louis and Bouillaud quote from M. Caillot 
the case of a child who became cyanotic at the age of two months in an 
attack of whooping cough. Louis also narrates a case in which whooping 

^ Medico-Chir. Trans., vol. xxv. 



108 MALFORMATIONS. 

cough had the same effect at the age of twelve years. Ribes treated a child 
in whom the blue disease began at the age of three years from a severe con- 
tiision of the fingers. In a case by Marx it commenced at the age of ten 
months from a blow on the back inflicted by the mother. In the Medical 
Times ami Gazette, for 1855, Mr. Speer gives the history of a female who at 
the age of thirteen years was put in a place requiring considerable exertion, 
and from this time was cyanotic. A patient whose case was related by 
Cherrier fell into a deep ditch in the winter season, and immediately after 
had a low fever, from which the blue disease commenced. In a case pub- 
lished by Tacconus the exciting cause was believed to be fright in conse- 
quence of a fall from a great height, and in another, related by Bouillaud, it 
was a blow received on the epigastrium after the patient had passed the age 
of fifty years. Similar cases are related by Mayo and Peacock. 

It will be seen that the exciting cause of cyanosis is usually such as pro- 
duces a profound impression on the system and affects the action of the heart. 
Precisely in what way it operates to develop the disease has not been satis- 
factorily explained. Mr. Mayo conjectures that in the case related by him 
there was previously some compensation which ceased or became inadequate 
in consequence of some change produced in the economy. Although cya- 
nosis may not appear for months or even years, there is rarely improvement 
when it is once established. Appearances of amendment are deceptive. The 
disease when not stationary is progressive, and this explains the fact that few 
survive the middle period of life. 

Symptoms. — The symptoms in cyanosis vary in intensity in different 
patients, and in the same patient at different times, being milder if he be 
quiet and the mind calm, more severe if active or if the mind be agitated. 
In mild cases, in a state of rest, they nearly or quite disappear, so that a 
stranger would not suspect that there was any serious ailment. They are 
aggravated by any cause which accelerates the action of the heart. In some 
patients cyanosis is increased by the most trivial disturbing influences, among 
which may be mentioned nursing, dentition, crying, coughing, and slight 
emotions of joy, sorrow, or anger. In more than one case it has been per- 
ceptibly increased by the stimulus of digestion, the color being deeper after 
a full meal than before. 

The cyanotic hue varies in different individuals from duskiness to a deep 
purple, almost black, color. It is usually most marked in the visage, especially 
the palpebrge, cheeks, nose, and lips, in the ears, fingers, and upon the mucous 
surfaces. It is sometimes, without any assignable cause, confined to a por- 
tion of the body. In a case related by Mr. Steel in the London Lancet, 
1838, the upper part of the body was livid and oedematous, and the lower 
part pallid and shrunken, and yet the malformation was of the kind which is 
commonly present in cyanosis. In the London Medical Times, March 8, 1845, 
copied from the Gazette medicale, is the history of a child, six years old, in 
whom the color was deeper on the right than left side. There had been, 
however, hemiplegia of this side in infancy, but this had entirely passed off. 
On the other hand, in a case of rare malformation communicated by Cooper 
to Farre, in which the upper part of the system was supplied chiefly by 
arterial and the lower by venous blood, the discoloration was general. In 
exceptional instances livid maculae, like those of purpura, have been observed 
upon the skin. 

Those affected with cyanosis have generally at birth been well formed 
and of the usual size, and in most cases for a considerable period after birth 
the appetite is good, bowels regular, and the system well nourished. But 
when cyanosis becomes so severe, as it does sooner or later, that its symptoms 
are rarely absent, digestion is imperfectly performed and the body becomes 



CYANOSIS. 109 

either emaciated or stunted and puny. It may be stated, as a rule, that 
nutrition is in inverse proportion to the gravity of cyanosis. In 33 out of 
41 cases in which the condition of the system as regards nutrition was 
recorded either a short time previously to death or at the autopsy, the body 
was either considerably emaciated or else diminutive, and those who were well 
nourished were usually such as had died early or of some intercurrent disease. 

In this connection may be mentioned two abnormalities which have been 
observed in the cyanotic. The chest is often flattened laterally with a pro- 
jecting sternum, so as to present an appearance generally described in the 
records as " pigeon-breasted." Sometimes the most prominent part is directly 
over the heart, and in one or two cases the sternum was observed to be 
deflected toward the left. In the majority of the records, however, no men- 
tion is made of the external appearance of the chest. 

The other abnormality is frequently observed in chronic diseases of the 
heart and lungs, in which there is sluggish circulation and consequent altered 
nutrition in the fingers and toes. In 28 of the cases collated by myself it is 
stated that the tips of the fingers or toes, or both, were bulbous. This 
hypertrophy, if slight, is likely to be overlooked, and that it was observed 
and recorded in so many cases renders it probable that it was present in a 
much larger number. In one case the anatomical character of this enlarge- 
ment was examined, and was found to consist chiefly of hypertrophied con- 
nective tissue. 

The nails are often incurvated over the deformity. At a meeting of the 
London Pathological Society in 1859, Mr. Ogle narrated the history of a 
laborer, fifty years old, who had swelling, numbness, and lividity of the left 
arm from pressure of an aneurism, and the fingers on this side were clubbed 
as in cyanosis. A patient whose history is related in the Glasgow Medical 
Journal^ and who was believed to be cyanotic in consequence of a highly 
emphysematous state of the lungs, had a similar development of the tips of 
both fingers and toes. 

An interesting feature in cyanosis is the low grade of animal heat. The 
temperature of the body is in all cases below that of health. This is espe- 
cially noticeable in the extremities. There has not been a sufiicient number 
of accurate thermometric observations to determine whether the internal heat 
is usually reduced. The following only have been recorded : Mr. Fletcher 
relates the history of a young man in the Medico-Chir. Trans., vol. xxv., in 
whom the thermometer placed in the mouth did not stand above 80° Fahr. 
Hodgson reports the case of a man, twenty-five years old, in whom the 
thermometer placed under the tongue rose to 100°. Perhaps a more thorough 
examination might have disclosed an intercurrent malady to cause the fever. 
In an examination recorded by Nasse the instrument placed in the mouth fell 
little if at all below the healthy standard ; applied to external parts, it stood 
at about 21° Reau. = 79.2° Fahr. 

The lack of heat is a source of great discomfort to a cyanotic patient. 
In mild weather he requires a fire to keep him warm or an amount of cloth- 
ing which to others would be uncomfortable, and in cold weather slight 
exposure strikes him with a chill. Nor can he increase his heat by active 
exercise, since his infirmity disqualifies him for this. 

Although the temperature of the surface is so low, the occurence of per- 
spiration, sometimes profuse, is mentioned in several of the records. 

In severe cases of cyanosis the generative system is imperfectly devel- 
oped. In the female menstruation is scanty or delayed, and in the male signs 
of puberty are feebly manifest. If the disease be so mild that the symptoms 
are absent when the patient is in a state of repose, these organs attain nearly 
or quite their normal development. The catamenia have appeared as early 



110 MALFORMATIONS. 

as the age of sixteen years, and a cyanotic patient treated by Cherrier had 
two children, but they both died of scrofulous affections. 

The action of the heart is necessarily much involved. In mild forms 
of the disease, if the patient be quiet, this organ may beat with considerable 
slowness and regularity, but in all cases exercise or excitement which in 
a state of health would scarcely have any appreciable effect on the pulse 
embarrasses its movements and produces palpitation. In severe cases pal- 
pitation is rarely absent, and the pulse is frequent, feeble, and often inter- 
mittent. In a large proportion of patients bruits are produced by the irreg- 
ular circulation through the heart. 

The respiration corresponds with the action of the heart. It is accele- 
rated in proportion to the frequency of the pulse. The suffering in this 
disease is largely due to paroxysms of palpitation and dyspnoea. These 
occur sometimes without any apparent exciting cause and when the patient 
is quiet, but they are commonly induced by those causes which we have 
already mentioned as aggravating the symptoms of cyanosis. They come 
on suddenly, and are attended by increase of lividity, distension of the jug- 
ulars, and sometimes of the cutaneous veins, and by a sensation of present 
suffocation. They last only a few minutes, and are succeeded by great 
depression of the vital powers. In infants, on account of greater nervous 
irritability and feeble power of endurance, these paroxysms often end in con- 
vulsions, which occasionally are fatal. A cough is sometimes present, but 
is usually slight. 

Pain is not a common symptom. Some of the patients complain occasion- 
ally of headache, with or without vertigo, and occasionally also of pain in 
the chest, but it is uncertain to what extent or whether these symptoms are 
dependent on the cyanotic disease. The secretions do not appear to be affect- 
ed, so far as has been ascertained. The same may be said of the intellectual 
and moral faculties. In a case related by Dr. Cheevers the child was even 
said to be precocious.^ The mind is capable of steady application and acqui- 
sition, as in health, provided that the emotions are not unduly excited. 

The cyanotic are liable to various forms of hemorrhage, but the records 
show that this liability is greater in youth and adult life than in infancy. In 
2 cases blood was vomited, in 1 passed by stool, in 1 it escaped from the gums, 
in 2 from the mouth, in 8 from the nostrils, and in 16 it was expectorated. 
Pulmonary phthisis was, however, usually present in these last cases. In 
the Western Journal of Medicine for 1829 an interesting case is related by 
Dr. William M. Voris of a girl nine years old in whom hemorrhage occurred 
under the scalp, producing great tumefaction and nearly closing the eye- 
lids. An incision was made, from which a pint and a half of dark blood 
escaped, and it was estimated that more than half a gallon was lost during 
the ensuing two weeks, at the expiration of which time the incision closed. 
The patient recovered from the hemorrhage, but not from the cyanosis. 

Toward the close of life more or less anasarca occasionally occurs, espe- 
cially around the ankles, sometimes in the eyelids and face, and rarely to a 
certain extent over the whole body. In certain patients it coexists with 
effusion in the serous cavities. 

It is evident that one who is affected with the severer form of cyanosis is 
disqualified for the duties of active life. The sports of childhood and the 
useful labors of mature years require an exertion for which he is physically 
unfit. He has not the ability even to engage in animated conversation, for 
he is overcome by emotions, whether of joy or sorrow. He lives almost 
an idle spectator of the world around him, prevented by his infirmity from, 
engaging in its pursuits. 

^ Lond. Med. Gaz., vol. xxxviii. 



CYAXOSTS. 



Ill 



Intercurrent diseases, especiall}' those of childhood, are badly tolerated, 
but whooping cough is the one which these patients are especially ill-fitted to 
endure. Still, they sometimes pass safely not only through whooping cougb, 
but through some of the most dangerous febrile diseases. It is a question 
of interest, but about which little is known with certainty, whether these 
intercurrent maladies are influenced by the cyanotic or venous condition of 
the blood. The symptoms of these maladies are no doubt more alarming, 
mainly on account of the embarrassed action of the heart, and not on account 
of the state of the blood ; still, it is reasonable to suppose that malignant 
and asthenic diseases are rendered worse by the lack of oxygen and excess 
of carbonic acid in the circulating fluid. 

Probably cyanosis does not furnish immunity from any other disease, 
although this statement has been made by a high authority. Rokitansky 
says: "All forms of cyanosis, or rather all the diseases of the heart, great 
vessels, and lungs adapted to produce cyanosis in a greater or less degree, 
cannot coexist with tuberculosis. Cyanosis aflfords a complete protection 
against it, and in this circumstance may be found an explanation of the 
immunity from tuberculosis which many conditions of the system, appa- 
rently very diff'erent in their character, afford."^ This opinion of the dis- 
tinguished pathologist, notwithstanding his ample opportunities for observa- 
tion and known accuracy as an observer, is not substantiated by statistics. 
So far from its being true, the low degree of vitality in cyanosis appears to 
favor the occurrence of tubercles. I have records of 26 cases of cyanosis 
in which tuberculosis was also present, in several of which the lungs con- 
tained cavities. This is about 13 per cent, of the whole number in my 
collection — a large proportion, since so many die in early infancy, at which 
period the tubercular disease seldom occurs. Cyanosis appears also to favor 
the development of cerebral diseases, especially congestion and coma, as will 
be seen presently. 

Prognosis. — This is unfavorable. Most cyanotic individuals die young. 
The age which they attain has been made the subject of statistical inquiry 
by Aberle. He states that in an aggregate of 159 cases, 57, or 35 per 
cent., died before the end of the first year ; 108, or more than two-thirds, 
died before the age of eleven years ; 30 between the ages of eleven and 
twenty-five years ; and of the remaining 21, only 5 lived more than forty- 
five years. 

The age at which death occurred is given in 186 of the cases collected by 
myself, as follows : 



In 17 under the age of 1 week. 
"10 from 1 week to 1 month. 



12 ' 


1 month to 3 months 


11 ' 


3 months to 6 " 


17 ' 


6 " to 12 '' 


12 ' 


1 year to 2 years. 


21 ' 


2 vears to 5 " 



In 21 from 5 years to 10 vears. 

" 41 " 10 " " 20 ' " 
u 20 " 20 " " 40 " 
" 4 over 40 " 

186. total. 



67. then, or more than one-third, died before the close of the first year; 121, 
or more than three-fifths, before the age of ten years ; only 24 survived the 
age of twenty years, and 4 the age of forty years. Of '^course the dura- 
tion of life depends on the nature and extent of the malformations. Some 
of these are such as render a speedy death inevitable. 

Mode of Death. — The mode of death is reported in 95 cases, as fol- 
lows : 



Handb. der Path. Anat, Bd. ii. 



112 MA LFORMA TIONS. 

19 died in a paroxysm of dyspnoea. 

10 " suddenly (the exact manner not stated). 

14 '' in convulsions (infants). 

2 " of apoplexy. 

7 " from hemorrhage. 

6 " of phthisis (though, as we have seen, 20 others had this disease). 

2 " of exhaustion, without hemorrhage, 

10 " of coma. , 

2 " of abscesses in the brain. 

One died of each of the following diseases : cerebral irritation, congestion 
of brain, effusion in the cranial cavity, acute hydrocephalus, paralysis from 
acute softening of the brain, dysentery, inflammation of heart, syncope, 
mucus in the air-passages, thoracic inflammation, choleraic diarrhoea, pneu- 
monitis, bronchitis, scarlet fever, croup ; 1 died in trying to walk, 1 after a 
spasmodic cough in pertussis, 1 after a long agony, 1 after an agony of ten 
or eleven hours ; 1 is reported to have died gradually and 3 quietly. 

The 10 who are stated to have died suddenly probably died in paroxysms 
of palpitation and dyspnoea, which are easily excited and of common occur- 
rence in cyanosis. If so, this was the mode of death in 29 cases. Infants 
with few exceptions, so far as appears from the records, died in convulsions. 
19 died of cerebral aff'ections, exclusive of convulsions, and in 13 of these ^ 
the cause of death was congestion, apoplexy, or coma. The hemorrhage of 
which 7 died was probably, in most instances, dependent on phthisis, and 6 
are said to have died directly of phthisis. We may, then, regard paroxysms 
of palpitation and dyspnoea, convulsions, congestive aff'ections of the brain, 
and phthisis as common modes or causes of death in cyanosis. 

The malformations of the heart and great vessels which give rise to 
cyanosis are quite numerous. The following table exhibits their character 
and relative frequency: 

Cases. 

1. Pulmonary artery absent, rudimentary, impervious, or partially obstructed 97 

2. Right auriculo-ventricular orifice impervious or contracted 5 

3. Orifice of the pulmonary artery and the right auriculo-ventricular aperture 

impervious or contracted 6 

4. Right ventricle divided into two cavities by a supernumerary septum . . 11 

5. One auricle and one ventricle 12 

6. Two auricles and one ventricle 4 

7. A single auriculo-ventricular opening ; interauricular and interventricular 

septa incomplete 1 

8. Mitral orifice closed or contracted 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed 3 

10. Aortic and the left auriculo-ventricular orifice impervious or contracted . 1 

11. Aorta and pulmonary artery transposed 14 

12. The cavse entering the left auricle 1 

13. Pulmonary veins opening into the right auricle or into the cavse or azygos 

veins 2 

14. Aorta impervious or contracted above its point of union with the ductus 

arteriosus; pulmonary artery wholly or in part supplying blood to the 
descending aorta through the ductus arteriosus 2 

Total 162 

From the above table it appears that in more than one half of the cases 
of cyanosis the congenital vice which gives rise to it is located in the pul- 
monary artery. It is located also, in general, in that part of the artery which 
is nearest the heart. Its character is difi'erent in different cases. Sometimes 
there is an arrested development of this vessel, and in its place we find simply 
a ligamentous cord extending from the heart as far as the ductus arteriosus, 
while beyond this point the artery and its branches are pervious ; rarely the 



CYANOSIS. 113 

entire artery is ligamentous, and of course impervious; in other cases this 
vessel is open through its whole extent, but the part nearest the heart is so 
small as to be properly considered rudimentary ; in others still there is adhe- 
sion of the valves to each other as the chief congenital defect ; and finally, 
in rare instances the obstruction in the pulmonary artery is due to an adven- 
titious membrane which stretches across the vessel like a diaphragm. These 
last malformations — namely, adhesion of the valves and the formation of an 
adventitious membrane — are doubtless due to inflammation occurring in the 
artery before birth, and some attribute the arrested development and lig- 
amentous state of the vessel to the same cause. 

In most cases of cyanosis due to obstructive malformations the inter- 
auricular and interventricular septa are more or less deficient. This 
deficiency obviously results from the obstruction, for the septa are formed 
in the heart after foetal circulation is established, and the blood, being pre- 
vented by the vicious formation from flowing in its proper channel, neces- 
sarily passes to the opposite side of the heart. More or less blood being- 
forced from one auricle or one ventricle to the opposite cavity, it is evident 
that a permanent aperture must result in the septum. The aperture in the 
septum ventriculorum is ordinarily at its base ; in the septum auriculorum it 
corresponds with the foramen ovale. 

In most of the obstructive malformations one, and rarely two, abnormal 
cardiac murmurs have been observed. The single murmur accompanies the 
ventricular systole. As it has been observed in cases of complete as well 
as incomplete obstruction, it seems to be due mainly to the flow of blood 
through a narrow or constricted pulmonary artery or the apertures in the 
septa. 

Modes of Compensation. — In most cases of cyanosis the congenital 
defect is partially obviated by modes of compensation. In the most fre- 
quent malformation, that in which there is obstruction in the pulmonary 
artery and a considerable part if not all the blood flows directly from the 
right to the left side of the heart, the ductus arteriosus not only remains 
open, but is greatly enlarged, through which a current of blood enters the pul- 
monary artery from the aorta, and, passing to the lungs, is oxygenated. The 
bronchial arteries have also been found greatly enlarged, and it is believed 
that though they are the nutrient arteries of the lungs, the blood which they 
eonvey to these organs is decarbonized in its circuit through them. In a case 
published by Mr. Le Grros Clark in the Medico-Chir. Tra7is., vol. xxx., the 
hronchial arteries were not only enlarged, but a " branch from the internal 
mammary artery, which accompanied the phrenic nerve, was nearly equal in 
size to the parent trunk, and expended itself principally in the adjacent 
adherent lung. Branches of the intercostal arteries have also been found 
enlarged, and entering the lungs or connecting with vessels which enter the 
lungs. By such modes of compensation cyanosis is rendered milder and life 
is prolonged. To these we must attribute the fact that some have very con- 
siderable malformation, and yet do not become cyanotic. 

Morbid Anatoimy. — This, as regards the circulatory system, has been 
sufficiently dwelt upon. No chemical analysis, so far as I am aware, has yet 
been made of cyanotic blood. We know that it is dark, its coagulability 
feeble — that it contains an excess of carbonic acid and is deficient in oxygen. 
From the nature of cyanosis it would be inferred that in many cases there is 
a, degree of passive congestion in the cavities of the heart, and consequently 
in the capillaries of the systemic system, giving rise to more or less serous 
efl"usion. Statistics show that this is so. The quantity of pericardial fluid 
is in some patients increased. I have records relating to this fluid in 51 cases. 
Usually it was pure serum. In IT the quantity was half an ounce or less, 
s 



114 MA LFORMA TIONS- 

if we include in the number those in which the amount is expressed in such 
terms as " due quantity," " usual amount," and " small amount." In 24 
cases the pericardial fluid (serum) exceeded half an ounce, usually estimated 
at from 1 to 6 ounces, but in 2 it exceeded the latter quantity. In 1 of the 
24 this fluid was stained with blood. In 2 patients the records state that 
there was a small quantity of pure blood in the pericardium, and in 1 the two 
pericardial surfaces were agglutinated by inflammation. 

In some of the autopsies serum was found in the pleural cavities, usually 
in connection with pericardial effusion, and in at least one instance this fluid 
was tinged with blood. Old adhesions between the costal and pulmonary 
pleura were observed in a few cases. The condition of the lungs was 
recorded with more or less minuteness in 110 cases. Mention has already 
been made of the large number affected with tubercular disease, which was 
either confined to the lungs or was chiefly exhibited in these organs. In 35 
patients the records state that the lungs were of small size, either by com- 
pression or sometimes, apparently, from the continuance of the foetal state 
over a greater or less portion of the organ. The compression was produced 
either by the distended pericardium or by effusion in the pleural cavities. In 
35 cases the lungs presented a dark color. This hue in some specimens 
accompanied the unexpanded or foetal state of the organ, but in others there 
was the normal inflation, and the dark color was due to engorgement or con- 
gestion. In other cases the lungs are stated to have been natural except the 
color. In 9 emphysema was present in a part of the lungs, in 2 pneumo- 
nitis ; in 2 the color of the lungs was pale, in 1 a bright crimson ; in 1 the 
lungs were larger than natural, in 1 the right lung was absent, and in 17 
these organs were recorded healthy. 

I have records of the state of the liver in 26 cases, in 16 of which it was 
enlarged, and in 4 of these it was congested. Congestion of the liver was 
present in 8 other cases in which no mention is made of its volume. The 
substance of the liver had a natural appearance in 9 cases, but in some of 
these this organ was enlarged. From these statistics it is probable that the liver 
is commonly enlarged in cyanosis, and not infrequently congested. In a few 
cases the condition of the other abdominal viscera is mentioned — in some as 
healthy, in others as congested. Fifteen examinations of the brain were 
made, in 7 of which congestion is recorded, and in 3 abscesses in the cere- 
bral substance, in 1 of which cases the lateral ventricle was also filled with 
pus ; in 2 softening of a portion of the brain had occurred, in 3 the brain 
was firm or compact, in 3 the quantity of fluid in the cranial cavity exceeded 
the normal amount, and in 1 it was less than normal. 

Theories relating to the Etiology of Cyanosis. — Although in 
nearly all cyanotic patients there are direct communications between the two 
sides of the heart, it is shown by many observations that these communica- 
tions or apertures are not sufficient in themselves to produce cyanosis. This 
opinion was expressed half a century ago by Louis, who published an excel- 
lent monograph on the subject of these communications, basing his remarks 
on an analysis of twenty cases. Since the publication of this paper, the 
belief has been pretty general in the profession — and observations continue, 
to substantiate it- — that although the apertures may be of considerable size, 
if the two sides of the heart, with their orifices and vessels, are in their nor- 
mal state, so that they act symmetrically and without obstruction, the blood 
is sufficiently oxygenated and decarbonized, and cyanosis does not occur. In 
proof of the correctness of this opinion many cases might be cited of a per- 
vious and some of a largely dilated foramen ovale without the cyanotic hue — 
cases which have been published in the journals since the appearance of 
Louis's monograph. Still, in cases of obstructive malformation, unless the 



CYANOSIS. 115 

obstruction be complete, cyanosis is more likely to occur in consequence of 
these apertures, for were they absent a larger amount of blood would be 
propelled through the narrow orifice of the pulmonary artery, and a larger 
amount consequently be ox3'genated. 

Allusion has already been made to the two theories which prevail in the 
profession : the one attributing the non-oxygenation of the blood and its 
highly venoas character, so as to cause the cyanotic hue, to the intermingling 
of venous and arterial blood : the other to obstruction at the centre of circu- 
lation, and consequent venous congestion. There are serious objections to 
the acceptance of either theory as an explanation for all cases. That admix- 
ture of the two kinds of blood is not essential to the production of cyanosis 
is apparent from the following facts : In one case in the Fourth Malformation 
there was no communication between the two sides of the heart, and the 
ductus arteriosus was closed, so that admixture was impossible. Again, in 
the Eleventh Malformation^ or that in which the aorta and pulmonary artery 
are transposed, the blue disease evidently does not depend on the admixture 
of the two currents. On the other hand, in this curious state of the heart 
the more the admixture the less the cyanosis, since the only waj^ in which 
the systemic current of blood can be oxygenated is by passing to the opposite 
side of the heart. An argument against this doctrine may also be found in 
the fact that the modes of compensation are not such as in an}'' way to dimin- 
ish or obviate the admixture. It is admitted that in the more frequent 
malformations cyanosis is increased by the apertures, which allow the inter- 
mingling of the venous and arterial currents, but it is more reasonable to 
consider the intermingling and the cyanosis as the direct results of the mal- 
formation, neither having the precedence of the other, than to consider that 
they are related to each other as cause and effect or as proximate and remote 
results. Viewed in this light, the admixture must be considered simply a 
concomitant of the cyanosis. 

The second theory, that of venous congestion, has numbered among its 
advocates many who have given special attention to the subject, as Morgagni, 
Louis, and Stille, but it seems to have even less claim for acceptance than 
the theory of admixture. It has been seen that in nearly all cases of cyanosis 
the two sides of the heart communicate freely, so that if the current of blood 
meets with an obstruction, as it commonly does, it readily escapes to the 
opposite side, where the artery is large and gives it free passage. In this 
way congestion, if not prevented, is greatly diminished. Again, it will be 
seen that, although certain of the viscera are frequently found at the autopsy 
more or less congested, congestion is not uniformly present in the organs, as 
it would probably be were it the proximate cause in all cases of c3'anosis. 

Moreover, in some patients the malformation is not obstructive. The 
cavities and their orifices are of the normal size, and cyanosis is due entirely 
to malposition of the vessels. It cannot be said that in these cases there is 
venous congestion from arrest at the centre of circulation. If there be any 
congestion, it must be due to the fact that venous blood does not circulate 
as readily as the arterial in the capillaries. It is true that in the paroxysms 
of dyspnoea there is sometimes more or less congestion — the distension of 
the jugulars, shows this — but it subsides with the paroxysms, and it prob- 
ably is no more than usually occurs when respiration is greatly embarrassed. 

In fine, attempts to express the immediate pathological state producing 
cyanosis in the terms of a general law have failed. However plausible the 
above theories may appear in regard to certain cases, there are others to which 
they are manifestly inapplicable. Those who advocate these theories seem to 
lose sight of the obvious fact that the chief want of the economy in cyanosis 
is decarbonization of the blood, and it is hardly supposable that there can be 



116 MALFORMATIONS. 

any correct theory of its causation which is not founded on this fact. With 
this physiological state in view, it does not seem difficult to express a theory 
in comprehensive terms which is applicable to all cases, such as the following : 
Cyanosis is 'due to malformations of the heart and the great vessels in imme- 
diate relation with the heart, which prevent the proper flow of blood to and 
from the lungs, so that the oxygenation and decarbonization of this fluid are 
inadequate. So comprehensive a statement includes not only cases of mal- 
formation and malposition of the heart and its vessels, but also those few 
cases in which the lungs are in fault. In most patients, as we have seen, the 
current of blood toicard the lungs is obstructed, and the current of blood /rom 
the lungs is obstructed in those comparatively rare cases in which the mal- 
formation is on the left side. 

Treatment. — From the nature of cyanosis it is evident that the treat- 
ment should be more hygienic than medicinal. The patient should be warm- 
ly clad and kept in a warm room, and all agencies calculated to embarrass or 
disturb the functions of the body or excite the emotions, and thereby accel- 
erate the heart's action, should be studiously avoided. The diet should be 
nutritious, but simple and easily digested. 

Those who have attributed cyanosis wholly to apertures in the interau- 
ricular and interventricular septa, and the consequent flo^ of blood from the 
right to the left side of the heart, have considered it an important part of 
the treatment to keep the patient reclining on the right side, so as to dimin- 
ish this flow by the effect of gravitation. The reader, however, must be 
convinced from the nature of the malformations that little benefit can accrue 
from following such advice. Still, patients are sometimes less cyanotic and 
more comfortable in one position than another. In a case reported by Mr. 
Howslip^ " the only easy and indeed comfortable position in which the child 
could remain was that usual in nursing. When erect the dusky color of the 
face and neck became a dark-blue." In a case related by Mr. Spackman ■^ 
the patient was easiest on the hands and knees. Louis reports a case ^ in 
which the selected position was with the head elevated; Wm. Hunter a 
case* in which the patient avoided paroxysms by lying on the left side. 
Struthers and King each report a case in which the patients seemed most 
comfortable while lying on the right side f but, on the other hand. Pro- 
fessor White of Buffalo ® and Dr. James Carson '^ report cases in which 
position on the right side failed to produce any alleviation of symptoms. 
Other similar observations might be cited, but enough have been mentioned 
to show that no one position should be recommended for cyanotic patients. 
Some obtain most relief by lying on the back, others on the right side, 
others on the left ; some when on the hands and knees, some when reclining 
on either side indifferently, while, finally, others suffer least when erect. 

There was a time when the paroxysms were treated by venesection, but 
depletion has long since been abandoned. Physicians now rely on stimu- 
lants, antispasmodics, friction to the chest, and mustard pediluvia to relieve 
the urgent symptoms, although this treatment is but partially successful. 
It is probable that of all internal remedies digitalis is the most useful, from 
the fact that it is an efficient heart-tonic and more than any other medicine 
gives strength and equality to the heart-beats. In the cities where oxygen 
gas can be procured for daily inhalation the urgent symptoms may in some 
instances be partially relieved by the use of this agent. 

1 Edin. Med. Jour., 1813. 2 ^^^^^ j/g^, (j„^.^ 1833. 

^ De la Commun. rfes Cav., etc. * Med. Obs. and Enq., vol. vi. 

^ Monthly Jour, of Med. Sci. ^ Buf. Med. Jour., 1855. 

'' Amer. Jour, of Med. Sci., 1857. 



CEPHA LJEMA TO MA . 117 



Caput Succedaneum. 

During the birth of the child extravasation of blood frequently occurs 
in the part of the scalp which presents. It results from the passive conges- 
tion which occurs in presenting parts, and is greatest in amount when the 
labor has been protracted and the labor-pains unusually severe. Caput suc- 
cedaneum is the term employed to designate the swelling thus produced. Its 
seat is in the loose connective tissue between the scalp and pericranium, and 
it consists partly of extravasated blood, but largely of serum which has 
transuded from the congested vessels before that degree of congestion 
required to effect the transudation of corpuscles or rupture of capillaries 
was reached. I have repeatedly had an opportunity to examine this tumor 
in stillborn infants brought from the lying-in wards of the Xursery and 
Child's Hospital, and have found when it was slight that it consisted almost 
entirely of serum, but ordinarily when dissected it presented the appearance 
of a bruise, with a large proportion of serum, the blood and serum infiltrat- 
ing the scalp to a greater or less distance beyond the appreciable limits of 
the tumor. Caput succedaneum requires no treatment. As it lies in the 
loose connective tissue of the scalp, its liquid permeates the open interspaces 
in this tissue in every direction, and is rapidly absorbed, while the tumor dis- 
appears. Its subsidence is usually complete within twenty-four hours. 

Oephal^matoma. 

Occasionally during birth blood is extravasated under the pericranium, 
detaching it from the bone. This commonly occurs in connection with caput 
succedaneum, and is observed when the latter declines. Its common seat is 
upon the occipital or parietal bone, near the posterior fontanel, most fre- 
quently upon the parietal, where the pressure during labor is greatest. Prof. 
Henoch states that the tumor does not obtain its maximum size immediately, 
but gradually increases by the continued escape of blood until the third day. 
The tumor may extend over the entire surface of the bone, but it does not pass 
beyond the suture ; the suture limits its lateral extension. Cases of bilateral 
cephalhematoma have been reported, but they are rare. The tumor is fluctu- 
ating, and the skin covering it has the normal appearance or a bluish tinge, 
or it may exhibit infiltrations of blood like a bruise. Since the pericranium 
elevated by the blood does not lose its vitality, it begins to secrete from its 
under surface preparatory to the formation of bone. In a few days we are 
able to detect by pressure with the fingers a hard projecting rim at the border 
of the tumor, the result of the secretion and bony formation at the point 
where the pericranium is in part detached and in part adherent. If the 
tumor is tense, we are unable to detect the bone underneath by pressure, and 
the hard elevated rim resembles the edge of an opening in the skull. The 
cephalaematoma when not disturbed apparently causes little or no suffering, 
but the infant evinces pain if pressure be made upon it. Usually in the 
second week absorption is so far advanced that the tumor is less tense, 
and on pressure the bone can be felt underneath it. Complete absorp- 
tion of the blood which has remained liquid usually occurs in four or five 
weeks. 

Not infrequently, when absorption occurs slowly, a thin layer of bony 
substance forms in a few weeks on the under surface of the pericranium. 
This causes a creaking sound when pressure is made upon it Some time 
since a specimen was presented to the New York Pathological Society by me, 
showing a cephaljematoma and the mode of cure. The child died about 
two months after birth, and the blood constituting the tumor, which had 



118 BISEASES OF THE NEW-BORN. 

been in great part absorbed, was completely encased by the old bone below 
and the new bony formation above. As the blood becomes absorbed the 
pericranium, having perhaps a bony formation on its under surface, grad- 
ually sinks ; the cavity at length becomes obliterated ; and there only remains 
some thickening of that part of the cranium which corresponds with the site 
of the tumor. 

A cephalaematoma might be mistaken by the inexperienced for a con- 
genital meningocele, since the ridge described above which forms along its 
border resembles so closely the edge of an opening, and both tumors are 
fluctuating ; but a meningocele rarely occurs upon the part of the head 
occupied by the cephalaematoma ; and if there be any doubt in the diagnosis 
at first, it will be dispelled in a few days by the changes which it undergoes. 

The TREATMENT should be expectant, except that a soft covering of cot- 
ton should be placed over it to prevent injury. Experienced physicians who 
formerly opened these tumors by an incision have abandoned this treatment, 
and recommend leaving them entirely to nature. 



CHAPTER II. 

DISEASES OF THE NEW-BOEN. 

Inflammation of the Sterno-cleido-mastoid Muscle. 

We sometimes observe in infants, usually between the ages of one and 
six weeks, a hard tumor upon the antero-lateral aspect of the neck cor- 
responding to the site of the sterno-cleido-mastoid muscle, and evidently 
developed in this muscle. It is round or more frequently elongated, varying 
from the size and shape of a pigeon's egg to that of the little finger, occupy- 
ing the anterior border of the muscle. Sometimes the tumor, hard like 
cartilage to the touch, extends over the anterior half of the muscle ; and it 
is stated to occur more frequently in the right than in the left muscle. Prof. 
Henoch observed it on the right side in 16 cases and on the left side in 5 
cases. 

The following was a typical case: On July 19, 1887, I attended Mrs. 

S , a primipara, in her confinement. Her labor, which was tedious, was 

terminated by the forceps, without any appreciable injury of mother or child. 
About one month after her confinement the mother stated that she had 
observed during the last two weeks an unusual swelling passing obliquely 
along the side of the neck of the child. I found the anterior portion of the 
sterno-cleido-mastoid muscle thickened and hard from a point about two 
lines above its lower attachment nearly its entire length. The swelling was 
of the size and shape of the little finger of a child of twelve years. It was 
tender to the touch, never had been red, and the infant's condition was nor- 
mal in every other respect. At the age of nine weeks the tumor was still 
appreciable, but had nearly disappeared. Sometimes the tumor is not con- 
tinuous, but the muscle is thickened and hardened in two or three diff'erent 
places. Occasionally the child's head is turned to one side, either from the 
pain in holding it erect or because the function of the muscle is impaired. 

The etiology and nature of this tumor are apparent from the history. In 
a majority of the cases the birth of the infants afiected with this ailment was 
tedious, and in many the presentation at birth was abnormal. This tumor is 



MASTITIS. 119 

especially liable to occur after breech presentations, which necessitate trac- 
tion upon the neck. In head presentations, when there is delay in liberating 
the shoulders and traction is made on the head, and especially if forcible 
rotation is made, the more superficial and exposed fibres in the sterno-cleido- 
mastoid muscle are liable to rupture ; and when this occurs a local myositis 
results, causing the tenderness, infiltration, and swelling. Certain writers 
state that more or less extravasation of blood takes place at the time of the 
accident, and before the inflammation supervenes, and hence the term " haema- 
toma " which has been employed to designate the disease. But I have seen 
no evidence of hemorrhage — none of the bluish discoloration which indi- 
cates extravasation so common in bruises— in any of the cases which I 
have observed. 

The PROGNOSIS is good. Suppuration does not occur unless under very 
unusual circumstances, and, though probably more or less cicatricial tissue 
results at the seat of injury, the function of the muscle is not appreciably 
impaired when the inflammation and swelling abate. No perceptible contrac- 
tion or deformity results. But little treatment is required ; indeed, patients 
do well without treatment. But it is best for the infant that it maintain so 
far as possible a horizontal position, with the head resting on a pillow and 
with the avoidance of rotation so long as the disease is in its active stage and 
the tumor is tender to the touch. Probably cool lotions recommended by 
some are as likely to do harm as benefit by giving cold to the child and pro- 
ducing nasal or other catarrhs. Inunction with an ointment of iodide of 
potassium has been recommended for the purpose of promoting absorption, 
as the following : 

R. lodidi potass., 

Aqnse, da. 1 part ; 
Ad i pis, 2 parts; 

Lanolin, 6-8 parts. 

But without this treatment absorption is progressive and cure complete 
within a few weeks. 

Mammary Glands. 

In newly-born infants the secretion of a milk-like substance begins at about 
the fourth day in the mammary glands. It increases until the tenth day, 
when it gradually diminishes, and disappears at about the twentieth day. it 
is attended with some swelling of the glands during the period of their 
activity, and after the secretion ceases the enlargement gradually abates. 
M. Gruillot states that this secretion presents under the microscope the appear- 
ance of colostrum.^ A section of the gland in which this secretion has 
occurred, made near the surface, shows epithelium. At a greater depth the 
canals enlarge, divide, and end in cavities which are filled with a liquid hav- 
ing the appearance and character of colostrum. This glandular activity, it is 
said, may begin before birth, and continue six or eight weeks after birth, but 
the period of greatest enlargement and most active secretion of the gland is 
usually between the fourth and tenth days after birth, as stated above. 

Mastitis. 

In exceptional instances the enlargement of the gland and its functional 
activity result more seriously. The gland becomes inflamed, and an abscess 
may occur as in the adult female. The nurse may produce this result by 

^ Archiv. de Med., 1853. 



120 DISEASES OF THE NEW-BORN. 

rubbing and pressing the gland, so that rude manipulation of it should be 
avoided. An abscess destroys the gland-structure, which is a serious result 
if the infant be a female. M. Bouchut, in his practical treatise on diseases 
of the newly-born (p. 719, 1867), relates a fatal case of mastitis in which 
the inflammation extended to the connective tissue, and ulceration so exten- 
sive occurred that the pectoral muscle was exposed, and death resulted from 
prostration. Dr. A. Jacobi has observed similar cases, ^ Therefore in treat- 
ing the enlarged and secreting gland of early infancy very gentle and unirri- 
tating measures should be employed, so that mastitis may, if possible, be 
prevented. The dress should be loose, so as to avoid pressure on the gland. 
If no inflammation, or inflammation in its commencement, be present, absorb- 
ent cotton or cotton soaked with sweet oil should be applied and covered with 
oil silk. It is proper also to apply a mild lead wash to the enlarged mam- 
mary gland, especially if it be hot. If it be indolent, iodide of potassium in 
glycerin, one part of the former to ten of the latter, may be used. If the 
gland be hot, and especially if it be red, a soft emollient poultice should be 
applied, as of bread and milk or flaxseed and water. If, unfortunately, sup- 
puration occur, an early incision should be made as far as possible from the 
nipple. In the subsequent treatment mild antiseptic washes, as boric acid or 
listerine and water, should be used. Corrosive sublimate should not be 
employed, as young infants are readily poisoned by it, and, for the same reason, 
carbolic acid should not be used or be used in a very weak solution. Iodo- 
form should also not be used, or used largely diluted by the addition of 
starch. 

Conjunctivitis. 

(Ophthalmia Neonatorum ; Purulent Conjunctivitis of the Newly-born.) — 
Difi"erent forms of conjunctival inflammation occur in the newly-born. 
In the mildest variety no appreciable swelling of the lids occurs, and only 
a little viscid secretion collects between the lids, which agglutinates them in 
sleep, and which the nurse readily removes by bathing them with tepid water 
or milk and water, and in a few days efi"ects a cure. On the other hand, the 
purulent form of conjunctivitis, which is observed on the second or third day 
after birth, and which arises from the reception between the lids of the vagi- 
nal secretion of the mother, always involves great danger to the eye, speedily 
producing opacity or destruction of the cornea, unless promptly and properly 
treated Between these two extremes conjunctivitis neonatorum occurs in dif- 
ferent grades of severity. 

Mild or Catarrhal Conjunctivitis. — This, as the name indicates, is a 
simple catarrh, attended, as stated above, by a slight viscid secretion from 
the lids and by little or no swelling. The secretion collects in the angles of 
the lids and along their margin. This mild conjunctivitis requires very sim- 
ple treatment. Warm water or milk and water should be gently applied by 
a large camel's-hair pencil, so as to wash away the secretion as soon as it 
forms, and sweet oil or vaseline should then be applied between the lids. 
With these simple measures this mild conjunctivitis disappears in a few 
days. 

If the secretion be more abundant and the lids perceptibly swollen, more 
active measures are required. Prof. Noyes states that there is a variety of 
catarrhal ophthalmia neonatorum which requires active treatment. In the 
cases alluded to the ocular surface is but slightly involved, having little or 
no hyperaemia, but the palpebral conjunctiva is hypersemic and the fornix 
thickened and swollen. The swelling of the fornix is the most marked ana- 

^ Archives of PedicUrics, March, 1888. 



COyjVXCTIVITIS. 121 

tomical character. The secretion has a watery appearance, and the lids are 
but slightly tumefied. The cornea does not become hazy and the sight is 
not impaired, but the watery discharge and the viscid secretion on the bor- 
ders of the lids continue for weeks, unless the case be promptly attended to. 
Prof. Noyes recommends for this form of catarrhal ophthalmia neonatorum 
the application several times daily of the boric-acid solution : 

B. Acidi l)orici, gr. xv ; 

Aqua?, 5J. M. 

He adds ; " But if a child is a month old and the discharge continue, and 
the fornix exhibit decided swelling, I have been obliged to use solutions of 
tannin and glycerin as strong as Qij, ad 5J, before the condition would yield. 
I had tried nitrate of silver in mild solution, and, unwilling to make it more 
caustic, had taken a solution of tannin gr. x, ad glycerinum 5J, but this had 
only a temporary good effect, and the disease was not subdued until the 
strong solution was applied. It was done every second day to the everted 
lidj and was of course quite painful."' 

Purulent Ophthalmia Neonatorum; GonorrhcEal Ophthalmia 
Neonatorum. — This is one of the most important diseases to which the 
neonati are liable, since, if not promptly and properly treated, it is very 
damaging to the eye, permanently impairing or totally destroying vision. 
It is produced by the lodgment in the eye of irritating matter, usually the 
gonorrhoeal vaginal secretion of the mother. A minute amount of the viru- 
lent matter is sufficient to set up the inflammation. Recent observations 
seem to show that in a considerable number of cases the poisonous matter 
is received, not during birth, but in the washing, or subsequently from the 
fingers of the nurse or mother, or through the medium of soiled towels or 
linen. Dr. Joseph A. Andrews, in an interesting paper on contagious eye 
disease published in the Xeiu York Medical Journal, 1886, quotes the follow- 
ing table from Theremin, showing the time of commencement in 476 cases, 
as follows : 

First to fourth day after birth 57 cases. 

Fourth to eighth day after birth 134 " 

Eighth to fourteenth dav after birth 94 " 

Later ' 104 " 

When the disease begins subsequently to the first week after birth, it is evi- 
dent that the infection occurs post-natum, the poison being conveyed to the 
eyes through the soiled fingers or sponges or cloths employed in the nursery, 
as stated above. 

The infectious principle contained in the gonorrhoeal discharge of the 
mother is now admitted to be a micro-organism, designated the gonococcus, 
discovered and described by Hallier in 1869 and Salisbury in 1873. The 
attention of the profession was especially drawn to it by Herr Neisser of 
Breslau in 1879, whose description of it was more full and accurate than 
that of his predecessors. Recently it has been carefully examined with the 
aid of coloring tests by C. W. Allen and E. C. Wendt of New York City, 
and their monograph relating to it is one of the best yet published. The 
gonococcus is a " comparativeh' large "' microscopic organism, round at first, 
but becoming elongated or oval, and then dividing by fission so as to become 
a diplococcus. Subsequently division in the opposite direction occurs, and 
this process continues until the pus-cell in which the gonococci lie is filled 
with these organisms. It is within the pus-cells, as we have stated, and not 



122 DISEASES OF THE NEW-BORN. 

on their exterior, that the segmentation and development of the gonococcus 
take place ; but diplococci may be observed in the intercellular fluid, prob- 
ably having escaped from the pus-cells. 

In acute gonorrhoea usually no other or but few other bacteria except the 
gonococcus are observed ; but in chronic gonorrhoea of both sexes other 
microbes are commonly present in addition to the gonococcus. That the 
contagious and virulent property of gonorrhoeal pus is due to the gonococcus 
seems to be fully established, but were the action of this organism limited 
to cases of gonorrhoea it would be less important as a pathological factor. 
Microscopic examinations show its presence in the pus of ophthalmia neona- 
torum, as well as in the vulvitis of childhood, when of gonorrhoeal origin, 
and the intense inflammation and rapid destruction of sight in the former 
disease are believed to be due entirely to its agency. 

Dr. Gayet, professor of ophthalmic surgery, Lyons, France, says that the 
detection of the gonococcus in infected pus is as simple and easy as that of 
albumen in albuminuria. He places a particle of pus on a glass slide, covers 
it by another slide, and presses the two together. They are then separated, and 
stained by dropping on them an alcoholic solution of methyl-blue mixed with 
an equal quantity of water. After two minutes the slides are washed freely 
with water, and each leucocyte is seen to have two, three, or four nuclei, " this 
being a special character of the disease, the increase in the number of nuclei 
heralding the approach of the gonococci, which will be observed as intensely 
blue spherical bodies in the interior of some of the leucocytes."^ If the 
gonococcus be found in a single leucocyte, of course the diagnosis is 
established. 

Symptoms. — Stellwag says : " The period of incubation after successful 
inoculation of the contagious material varies between some hours and days. 
The outbreak of the blennorrhoea follows the more quickly the more favorable 
are the conditions for the inoculation — /. e. the more powerfully the secretion 
was able to act." In most instances when infection occurs during birth some 
evidence of the disease appears as early as the second or third day. The 
inflammation is from the first severe. The conjunctiva, ocular and palpebral, 
is intensely hyperaemic ; chemosis soon occurs in most instances, and an abun- 
dant nmco-purulent or purulent secretion flows between the lids mixed with 
tears. The inflammatory hyperaemia not only extends over the entire con- 
junctiva, but also to the connective tissue and the integument of the lids, 
causing in the latter a dusky or bluish-red tint. At a later stage the tint 
may be yellowish-red. The eyelids swell rapidly in consequence of the loose- 
ness of their connective tissue and the great amount of infiltration, so that 
they appear as projecting tumors pressing against each other and upon the 
eye, concealing the latter from view. The ocular conjunctiva, from the great 
amount of serous exudation underneath, rises up like a circular wall around 
the cornea, which appears sunken in the centre of the swelling, and some- 
times only its central part is visible in consequence of the bulging of the 
swollen conjunctiva over it. The palpebral conjunctiva is so sv/oUen from 
the serous infiltration that it bulges forward on attempting to separate the 
lids, and eversion of them is liable to occur. From the great amount of. 
tumefaction of the lids the palpebral fissure is closed, and the upper lid may 
project over the lower so as to nearly cover it. 

The danger to the eye results chiefly from the chemosis, or hard and tense 
oedema, of the subconjunctival areolar tissue, which by its pressure may ob- 
struct circulation. The eye is photophobic, tender to the touch, and the seat 
of severe pain. The intensity of the inflammation gives rise to active fever. 
The inflammation, having reached its maximum, soon begins to abate under 

^ La Province medicale ; Lond. Lane, June 18, 1887. 



CONJUNCTIVITIS. 1 23 

correct treatment ; the bright-red erysipehitous hue of the iids changes to a 
bluish color ; the heat and tenderness abate. The secretion is abundant, and 
is constantly escaping from the conjunctival sac and flowing over the cheek, 
which is often reddened in consequence of its extreme acridity. If in the 
height of the inflammation we attempt to separate the lids, which are firmly 
pressed together not only in consequence of the great amount of tumefac- 
tion, but also from the spasmodic contraction of the orbicularis palpebrarum, 
the purulent secretion gushes forth, consisting of greenish or grayish pus — 
a thick liquid containing flocculi of epithelial cells and muco-pus. Occasion- 
ally, when the inflammation is intense, these flocculi contain also fibrin. The 
discharge, consisting chiefly of muco-pus mixed with tears, has a creamj^ 
appearance, but if the lachrymation be abundant it may resemble whey in 
color and consistence, especially in the declining stage. 

Course ; Results. — Purulent conjunctivitis of the new-born usually 
begins in one eye, and unless the sound eye be immediately and effi- 
ciently protected, the inflammation ordinarily soon attacks this eye. Of 
course both eyes may be simultaneously affected, but in a large proportion 
of patients there is an interval of a day or two in the commencement of the 
inflammation in the two eyes, that secondarily infected receiving the virus 
from the one first attacked. 

In the milder cases the inflammatory symptoms, the hypersemia, tumefac- 
tion, heat, and secretion increase gradually, and it is not until the fifth or 
sixth day that they attain their maximum. In severe cases the symptoms 
reach their height by the close of the second or third day. The inflamma- 
tion, having attained its maximum, as indicated by the heat, swelling, and 
abundant secretion which wells up between the lids, soon begins to abate 
under correct treatment. But several weeks elapse before the normal state is 
restored, a simple catarrhal inflammation continuing after the purulent and 
infective secretion has ceased. 

The danger to the eye depends upon the severity of the inflammation. 
If the chemosis be not great, and the swelling be more oedematous than indu- 
rated, and the amount of secretion moderate, the eye is usually saved by 
timely and correct treatment. In severe inflammation characterized by great 
chemosis, hyperasmia, and heat and an abundant purulent discharge, the 
peril to the eye is imminent, since the inflammation is likely to extend from 
the conjunctiva to the cornea, and ulceration result. When the cornea 
becomes cloudy in places the danger to the eye is extreme, but the sight may 
be preserved, though abscesses and ulcers occur, provided that they are small 
and involve only a part of the cornea. Abscesses and ulcers near the margin 
of the cornea are less dangerous than those in the centre, but crescentic 
peripheral ulcers are of bad import, since they are likely to increase. If 
marginal softening and a central abscess or ulcer coexist, the sight will prob- 
ably be lost. Of course the more quickly the inflammation is subdued the 
better the prognosis. 

Preventive Measures. — Since purulent conjunctivitis of the new-born 
is so rapid in its progress and so destructive to the eye, it is very important 
that its occurrence should so far as possible be prevented, and, fortunately, it 
is a preventible disease. The employment of efficient preventive measures is 
one of the recent achievements in midwifery practice. Statistics abundantly 
show the need and efficiency of such measures. At the meeting of the Blind 
Congress, held in Paris in 1879, F. Dumas stated that of 1178 blind patients 
whom he had treated. 1070 became blind from curable diseases, and of this 
number, 817, or 69 per cent., lost their sight from ophthalmia neonatorum. 

According to Horner, of the blind children treated in the institutions of 
Germany and Austria, from 20 to 79 per cent, lost their sight from this dis- 



124 DISEASES OF THE NEW-BORN. 

ease} This was before the efficient prophylactic measures now in use were 
employed. 

Inasmuch as this malady is produced by the infective vaginal secretion 
of the mother coming in contact with the eye of the infant at birth, the use 
by the mother of antiseptic and disinfectant vaginal douches before and dur- 
ing parturition is suggested as the appropriate preventive treatment in case 
she have a muco-purulent discharge. For this purpose carbolized vaginal 
injections have been employed, with the result' of diminishing the number 
of cases of ophthalmia neonatorum. Mules'" advises the following very judi- 
cious and important preventive measures : " 1st. Cure all cases of chronic 
vaginal discharge before labor. 2d. Irrigation of the vagina during the 
second stage of labor when vaginitis is known to exist. The solution used 
for this purpose in Queen Charlotte's Hospital is corrosive sublimate (1 : 2000). 
The copious secretion of a clear vaginal fluid before and during labor, and 
the flow of the liquor amnii just before the birth, diminish the danger. 3d. 
Assist the foetal eyes to pass beyond the perineal edge without resting. This 
is easily done by hooking around the perineal edge with the fingers and draw- 
ing it down. 4th. By wiping the eyes with a clean cloth at birth of head. 
5th. By iiistilling an antiseptic solution into the eyes at birth if the mother 
has a discharge. 6th. Crede's method : to wash the face first, never in water 
in which the body has been washed. 7th. To retain one sponge or flannel 
especially for the child's face, and insist on scrupulous cleanliness. 8th. The 
nurse to wash her hands after adjusting the mother before touching the 
child. 9th. Not to expose child unduly to draughts, bright light, etc. 10th. 
To protect the child from flies with a thin veil. 11th. To remove carefully 
the child from the presence of another similarly affected ; strict isolation of 
an infected case. 12th. To guard the one eye if the other is aff"ected." The 
10th and 11th rules are evidently applicable to cases in maternity wards^ 
rather than to those in private practice. 

But in order to gain the highest degree of success by preventive meas- 
ures, it has been found necessary to treat the eyes of the infant immediately 
after birth if there be the least reason to suspect the presence of an infective 
vaginal discharge in the mother, so as to destroy the poison if it have lodged 
in them. In the lying-in asylums, where, in consequence of the prevalence 
of gonorrhoea in the mothers, ophthalmia neonatorum of a severe form has 
been prevalent, antiseptic treatment of the eyes of all the newly-born has 
either entirely prevented this disease or rendered it of rare occurrence. To 
Crede of Leipzig more than to any other physician the credit belongs of 
having established this treatment. Its efficacy is now universally recognized. 

Bathing the eyes of infants immediately after birth was previously prac- 
tised by Abegg, who employed only water, and by Olshausen, who, through 
Von Graefe's advice, employed a 1 per cent, solution of carbolic acid. 
Although this treatment diminished the number of cases of ophthalmia, it 
was far surpassed in efficiency by that recommended by Crede, who in 1880 
began to treat the eyes of the newly-born in the following manner : The 
external surface of the lids was first washed with plain water ; the lids were 
then separated, and a single drop of a 2 per cent, solution of nitrate of silver 
was allowed to fall upon the cornea from the end of a glass rod. From 1880 
to April 1, 1883, Crede treated 1160 infants in this way, and only 4 became 
aff"ected with ophthalmia neonatorum. This treatment by nitrate of silver, 
employed in other institutions in Europe and in this country, has been fol- 
lowed by signal success. Thus, Dr. Garrigues of New York employed 
Crede's treatment in the Maternity Hospital on Blackwell's Island, where 
ophthalmia neonatorum had previously been of common occurrence, and of 
^ArcJiivfUr Gyndkologie, 1883. ^ Prize Essay, Manchester Chronicle, Jan., 1888. 



CONJUNCTIVITIS. 125 

351 infants born consecutively "not a single one was affected."' Dr. Glar- 
rigues adds that in these cases occasionally a thin discharge like serum fol- 
lowed the application of nitrate of silver, due apparently to its irritating 
action, and that the first cases in which he observed this discharge he treated 
with iced compresses and the instillation of a saturated solution of boric 
acid. But afterward he found that they quickly recovered without such 
measures. Occasionally so many drops of the nitrate were inserted by acci- 
dent that a black ring was produced upon the eyelids, without any ill effect 
to the eye. Dr. Grarrigues recommends Crede's method of employing a glass 
rod, to which a single drop of the solution adheres, so that there is no risk 
that more than this amount will be instilled. The application should be 
made as soon as the infant is removed from the bed to the lap of the nurse. 
She should first clean the eyelids and the face, and in washing them should 
be careful that none of the wash enters the eyes. A weaker solution of 
nitrate of silver has been employed without the good results which follow 
the use of the 2 per cent, solution. Crede made tentative use of borate of 
sodium (1 : 60), and found it greatly inferior as a preventive to the nitrate 
of silver.^ 

Of course preventive treatment of this kind should not be recommended 
in general midwifery practice, except when there is evidence or strong sus- 
picion that the mother has gonorrhoea. Moreover, much can be done toward 
diminishing the number of cases of blindness resulting from ophthalmia 
neonatorum by disseminating among the masses a knowledge of the immi- 
nent danger to the sight of the newly-born infant when a purulent discharge 
occurs from its eyes, so that instead of employing domestic remedies the 
parents will seek at once the advice of the accoucheur or family physician. 

Treatment. — No disease of early life so imperatively requires early, per- 
sistent, and correct treatment as the purulent form of ophthalmia neonatorum. 
If proper measures be employed sufficiently early and persistently, the eye 
can nearly always be saved. Since this malady has a microbic origin, it is 
evident that an efficient germicide is required in the treatment — an agent that 
does not injure the eye, while it destroys the cause of the inflammation. 
Various germicides have been employed for this purpose, but the two which 
have been found safest, and at the same time most efficient, are corrosive sub- 
limate and nitrate of silver. 

The late Prof. S. D. Grross long before the microbic causation of the 
infectious diseases was known, and before antiseptic treatment had come into 
use, had in his large clinical experience discovered the efficacy of the cor- 
rosive-sublimate treatment. In his System of Surgery, published in 1859, he 
wrote : '' In the purulent ophthalmia of infancy I have usually effected excel- 
lent and even rapid cures by the injection every few hours of tepid water or 
milk and water, followed immediately after by a solution of bichloride of 
mercury, from the eighth to the twelfth of a grain to the ounce of water ;" 
and again he wrote : " The bichloride of mercury is, of all the local remedies 
that I have ever tried in this affection, the most efficacious in its action, mak- 
ing generally a most rapid and decided impression upon the discharge." 
Oppenheimer of Heidelberg in his experiments on the gonococcus, which he 
cultivated in blood-serum, found that corrosive sublimate, 1 : 40,000, retarded 
its development, and 1 : 20,000 destroyed its vitality.^ Nitrate of silver was 
also used in the treatment of purulent ophthalmia neonatorum long before 
the gonococcus was discovered, and before the need and efficacy of germicide 
remedies in the treatment of the infectious diseases were known or recog- 
nized. Yon Grraefe more than thirty years ago everted the lids when it was 

^ Amer. Jour, of Med. Sci., Oct.. 1884. ^Arch.f. Gynak., xxi. p. 193. 

3 Andrews : N Y. Med. Jour., Sept. 25, 1886. 



126 DISEASES OF THE NEW-BORN. 

possible, applied the mitigated stick of nitrate of silver to the mucous sur- 
face, washed it with salt, and replaced the lids. This treatment is still 
employed by some specialists in ophthalmic practice. Dr. Gayet^ everts the 
lids so as to stretch the mucous membrane, when he thoroughly washes the 
folds of the conjunctival sac by means of a ball syringe. The lids are 
replaced, rubbed so as to displace pus-cells and force them into the con- 
junctival sac, again everted and syringed. The mitigated stick is then 
applied to the palpebral mucous membrane, and the nitrate of silver imme- 
diately neutralized and washed away by a solution of chloride of sodium. 
The lids are then replaced. In the subsequent treatment the mother or nurse 
washes the eye with a solution of corrosive sublimate (1 : 6000), and frequently 
renews upon the lids compresses wet with ice-water. But most of the lead- 
ing oculists employ nitrate of silver in solution in the manner presently to be 
described. 

We again call attention to the necessity in this disease, more than in 
almost any other, of employing faithful and attentive nurses, who will carry 
out punctually the directions given. Two nurses are required — one to serve 
by day and the other by night — since it is essential that the eye be fre- 
quently cleaned and the secretion washed away. 

If the conjunctivitis be purulent, but mild, and attended by a slight dis- 
charge and little or no appreciable swelling of the conjunctiva, two drops of 
a 2 per cent, solution of nitrate of silver should be instilled once between the 
lids, and the lids moved to ensure its flowing underneath them : 

R. Argent, nitrat., gr. vj ; 

Aq. destillat, ^v. M. 

In the subsequent treatment a strong solution of boric acid — some recom- 
mend a saturated solution — should be instilled every half hour, the lids being 
drawn widely apart. The frequent wide separation of the lids, which can be 
accomplished without undue pressure upon the eye, is useful in allowing the 
pus to escape, as well as in facilitating the application of the wash. I prefer, 
however, unless the disease yields quickly, the use of a weak solution of 
corrosive sublimate in place of the boric acid, employing the following 
formula : 

R. Hydrarg. chlor. corros., gr. j-ij ; 

Aquae destillat., Oj. M. 

The use of this mild solution of the sublimate every second hour after a 
single employment of the nitrate of silver usually suffices to cure mild cases 
in a few days. 

If the disease be more severe, but still mild, and accompanied by mod- 
erate tumefaction and a moderately increased secretion, a single daily applica- 
tion of the nitrate of silver suffices during the active period of the inflamma- 
tion. In severe forms of the disease, accompanied by much tumefaction and 
the frequent gushing out between the lids of a thick, purulent secretion, the 
nitrate-of-silver solution should be used as often as every six hours. Dr. 
David Webster of the Manhattan Eye and Ear Hospital states that he has 
employed the nitrate of silver in these severe cases five times in twenty-four 
hours with great benefit. As regards the frequency of the application of 
nitrate of silver, and the time when to desist from its use, Andrews writes : 
" The only guide which I know is the condition of the conjunctiva. W^hen 
there is slight hyperaemia only, the slough produced by the nitrate of silver 
requires a long time to be cast ofl"," and it is very irritating. But if there 
^ La Province medicale ; London Lancet, June 18, 1887. 



UMBILICAL VEGETATIONS. 127 

be a more severe inflammation, with much swelling, the slough is thrown off 
in a few hours. The use, therefore, of nitrate of silver at intervals of a few 
hours should be practised only in the most severe forms of the inflammation, 
while in the milder cases it should be used only once or at long intervals. In 
the declining period of the disease the application of a solution of boric acid 
or a weak solution of corrosive sublimate, gr. 1 to the pint of distilled water, 
suffices to eff"ect a cure. 

Umbilical Vegetations. 

Not infrequently small excrescences sprout out from the base of the 
umbilical depression at the time or soon after the fall of the cord. They 
have the appearance of those vegetations which arise from open sores, and 
which have been designated, in common parlance, proud flesh. One of the 
first, if not the first, monograph on these outgrowths appeared in the Jltdi- 
cal Dictionary in 1834 from the pen of M. Duges. They have been desig- 
nated in diff'erent languages by many appellations, as fungous excrescence 
of the umbilicus (Condie), excrescence of the umbilicus (Cooper Foster), 
warty tumor of the umbilicus (Holmes), bourgonnement de I'ombilie (De- 
paul), granulorae de I'ombilie (Dechamber), vegetation ombilicale (Guer- 
sant). Virchow has also alluded to them in his treatise on tumors, and a 
carefully-prepared and instructive monograph relating to them appeared in 
the Rev. Mem. des Malad. de V Enfancp. Juillet, 1886, from the pen of M. 
Broussole. 

The size attained by these growths is always small. Many of them are 
not larger than a pea in their greatest development. Their form appears to 
be determined in a measure by the external pressure. Some are rounded, 
and others are elongated or cylindrical, French physicians have likened 
them, as regards appearance, to a small strawberry or a small cherry, and 
sometimes, when small and elongated, they have been likened in shape to a 
grain of wheat or barley. Guersant and Owen have described them as hav- 
ing a nipple- or polypus-shape, according to variations in their base. It is 
only in exceptional instances that they have so red a tint as a strawberry or 
cherry. Their color varies from a pale red to a red of a deeper tinge, accord- 
ing to the degree of vascularity, and they are always moist. 

This outgrowth is distinguished by its irreducibility and its consistence. 
Digital pressure may cause it to disappear in the umbilical fossa : it dis- 
appears by depressing the floor of the fossa. It reappears in its entirety by 
the resiliency of the walls of the fossa as soon as the pressure is removed. 
It has the soft consistence of fungous tissue, so that it is depressed and flat- 
tened and its shape changed even by slight pressure. It arises in most 
instances from the inferior part or floor of the umbilical fossa, and it con- 
trasts in appearance with the cutaneous folds of the umbilicus by its soft- 
ness and reddish tinge. 

This tumor does not ethibit any tendency to ulceration or to hemorrhage 
in the proper sense of the term, but a sanguinolent serum exudes from it 
and stains the linen unless the growth be small. The thin irritating dis- 
charge from the surface or base of the vegetation sometimes causes small 
excoriations upon the edge of the fossa. In a child of one year and a half, 
whose case is detailed by Foster, the ulceration from this cause attained con- 
siderable size. It is said that cases have been observed in which the red- 
ness increased when the infant cried, and other cases in which the vascu- 
larity was such that more or less hemorrhage occurred when the tumor was 
injured. In these last cases umbilical nsevi may have been mistaken for 



128 DISEASES OF THE NEW-BORN. 

Progress. — This vegetation in the first days or weeks increases more 
rapidly than subsequently. It may attain half the size or the full size of a 
pea, or even a greater development, by successive sprouting of granulations. 
It may increase slowly during many weeks or months, or it may come to a 
standstill and show no tendency to diminish or atrophy. In time, according 
to several writers, it is likely to shrivel and skin grow over it, and thus be 
cured. But more frequently surgical interference is required. 

Etiology. — It is reasonable to suppose that some excoriation of the sur- 
face precedes the granulations, and affords the base on which they arise ; but 
why one child has this outgrowth, while another child, with the same man- 
agement of the cord and apparently the same condition of the umbilicus, is 
free from it, does not perhaps admit of explanation. 

Diagnosis.— This is readily made. The small size, irreducibility, red- 
dish hue, the serous oozing which stains the linen yellow, the softness, like 
exuberant granulations in other localities, and the shape, enable the phy- 
sician to diagnosticate this growth from any other kind of acquired tumor. 
An umbilical nsevus has greater firmness and a deeper red color, which dis- 
appears on pressure and becomes more pronounced when the infant cries. 
The naevus is also less elevated, and it extends laterally and vertically far- 
ther than the vegetation, often passing beyond the umbilicus. From other 
tumors occurring at the umbilicus, as adenoma and sebaceous and other 
cysts, the diagnosis is easily made, since tumors other than the vegeta- 
tions and naevus are covered with skin, are not attended by the serous 
oozing which stains linen, and most of them are congenital. 

Histology. — M. Albarran and others have made microscopic examina- 
tion of these vegetations, and found that they consisted of frail, feebly-organ- 
ized connective tissue, round cells with large nuclei, capillaries with walls 
consisting of swollen endothelial cells, and vessels of larger size with narrow 
lumina and with walls formed by concentric layers of flattened fusiform cells. 
In another case examined microscopically fasciculi crossed each other, form- 
ing alveoli which contained cellular elements that were abundant in propor- 
tion to the fibrillar stroma. The vegetations always contain numerous small 
blood-vessels, true embryonic capillaries, with walls consisting of young 
cells arranged concentrically. They are made up of these small vessels, 
frail connective-tissue cells, and some granular intercellular substance. 

Treatment. — Cauterization by nitrate of silver acts slowly, but some- 
times destroys the vegetation if small. More efficacious and preferable 
treatment is to remove the growth by the scissors or ligature. Saint-Ger- 
main operates as follows: The fold of the skin surrounding the umbilicus 
is depressed, while slight traction is made on the excrescence by the forceps. 
The pedicle is then strongly tied by a silk thread previously dipped in a solu- 
tion of carbolic acid. Slight traction then suffices to remove the growths, 
and they sometimes drop off in the tying. After the removal a little iodo- 
form should be dusted into the umbilical fossa, and the umbilicus covered by 
a pledget of surgeon's lint retained in place by strips of adhesive plaster. 

Umbilical Hemorrhage. 

Hemorrhage occurring at birth or soon after from too loose ligation of the 
cord, or from its laceration, is so well known and its cause so apparent that it 
need only be alluded to in this connection. Bouchut relates a case in which 
death took place from this cause even before birth. The child was attached 
to the placenta by a navel-string so short that it prevented delivery till it 
parted by the traction of the forceps. The bleeding from the umbilical ves- 
sels was so profuse that the child was pallid and lifeless when born. 



UMBILICAL HEMORRHA GE. 



129 



But another form of umbilical hemorrhage sometimes occurs in the new- 
ly-born. The oozing takes place from the umbilicus itself, and not from the 
loosely-tied or torn umbilical cord. One of the first cases on record of this 
hemorrhage was published in the Gentleman s Gazette^ in April, 1752, by Mr. 
Watts of Kent, England ; but after the publication of this case a century 
elapsed before umbilical hemorrhage attracted the attention which it merited. 
In April, 1852, Dr. Francis Minot read a paper on this disease, containing 
the statistics of 46 cases, before the Boston Society for Medical Improvement. 
Three years subsequently, in 1855, Dr. Stephen Smith of New York read a 
monograph on the same subject, containing the statistics of 79 cases, before 
the New York Statistical Society. This was followed in 1858 by a statis- 
tical paper from the pen of Dr. J. Foster Jenkins, read before the United 
States Medical Association and published in its Transactions for that year. 
This monograh was elaborate, since the writer succeeded in obtaining 
the histories of 178 cases from medical journals and members of the 
Association. 

Sex; Age. — In the cases collated by Jenkins, 341 per cent, were females 
and 65| per cent, males. However, it seems improbable that sex produces 
any difference in the liability to umbilical hemorrhage. The following table 
gives the ages at which the hemorrhage began in 99 cases : 



Age. 
On the 1st day 

" " 2d "' 

" " 3d " . 

" " 4th " 

5th to 7 til day, inclusive 32 



No. 
5 
7 
6 
3 



Age. No. 

8th to 10th day, inclusive 25 

11th to 15th "' '' ..... 16 

16th to 21st " " 4 

•22d to 56th " " J 

99 



These statistics are interesting as showing the relation of the hemorrhage 
to the umbilical cord. In the 18 cases in which the hemorrhage occurred 
under the age of three days it may be assumed that the cord was attached, 
and the blood escaped from the walls of the umbilical fossa outside of the line 
of its attachment. Immediately after the fifth day, or after the time when 
the cord falls, there was a large increase in the number of cases, so that 
from the fifth to the fifteenth day after birth was the period of greatest 
liability to the hemorrhage. Since, as many observations have shown, in a 
large proportion of cases the blood has feeble coagulability, it seems probable 
that the umbilical vein and the umbilical and hypogastric arteries may not 
have been occluded by fibrinous coagula in at least some of these patients, 
as they commonly are in the healthy, and that the hemorrhage occurred in 
part from these vessels. This hypothesis is rendered more plausible by the 
fact that from the general ill-health present in many of these infants, prob- 
ably the walls of the vein and arteries were lacking in contractility, so that 
they remained more patulous than in robust and healthy infants. 

Causes. — Hemorrhage from the umbilicus, as well as from other parts in 
the newly-born, must be referred to a faulty composition of the blood, espe- 
cially its feeble coagulability, or to an abnormal state of the walls of the 
minute vessels, or to both these causes. The hemorrhage is sometimes refer- 
able to the hemorrhagic diathesis or haemophilia, which may be inherited or 
may result from obscure causes in children born of healthy parents. In 
the New York Infant Asylum a well-developed and apparently healthy 
mulatto woman gave birth to her first infant on November 30, 1886. She 
stated that her family were healthy and that the father of the child was also 
in excellent health. The birth was easy and natural, and nothing unusual 
was observed in the infant, which weighed nearly ten pounds, except a swell- 
ing from extravasated blood above and in front of the right ear. At 7 A. M. 



130 DISEASES OF THE NEW-BORN. 

on the next day severe umbilical hemorrhage occurred, which was checked 
by styptics ; then slight epistaxis took place. At 11 a. m. bleeding from the 
navel returned, and appeared to come from several points at the margin of 
separation of the floor of the umbilicus from the cord. The tumor above 
the ear increased, purpuric spots appeared upon the integument, and death 
occurred from exhaustion on December 2d. The infant lost one pound in 
weight during the two days of its existence. At the autopsy a few small 
superficial erosions could be made out in the umbilical fossa at the point of 
union with the cord. The umbilical vein, traced to the liver, and the hypo- 
gastric arteries, traced to the iliac arteries, contained no blood, were patulous, 
and apparently normal. Extravasations of blood were found under the skin, 
in the abdominal cavity, and at numerous points in the lungs, etc. The 
organs had an exsanguine appearance, and everywhere the blood was without 
clots, its fluidity being a notable peculiarity The cause of the haemophilia in 
this child was not apparent. Its parents, so far as could be ascertained, were 
healthy ; still, it may have belonged to a family of bleeders, for the hemor- 
rhagic diathesis sometimes passes over one generation and reappears in the 
next. 

Syphilis is one of the recognized causes of the hemorrhagic diathesis in 
the newly-born. In 1871, I was requested to visit a neonatus that was a 
bleeder, whose father was unmistakably syphilitic, and whose mother was 
suspected to have contracted syphilis from her husband. The child was 
fairly developed, and the cord separated on the sixth day. A constant 
oozing of blood from the navel commenced on the seventh day, on account 
of which T was summoned to the case. I finally succeeded in arresting the 
bleeding by the application of the plaster-of-Paris dressing, but immediately 
intestinal hemorrhage commenced, of which the child died in twenty-four 
hours. The parents were induced to take antisyphilitic remedies for a con- 
siderable time, and they have since had four healthy children. In another 
instance observed by me, an infant, puny and apparently premature, was at 
birth observed to have several blebs of pemphigus, from which blood soon 
began to ooze, but the umbilical hemorrhage from which the child died did 
not begin until about the fourteenth day. 

Two elements or factors appear to be present in producing hemorrhagic 
syphilis in the newly-born. We have already alluded to abnormal fluidity 
of the blood, for when it escapes it does not coagulate or its coagulation is 
very inadequate. The other factor is abnormalities in the minute vessels. 
Many years ago the eminent obstetrician Sir James Y. Simpson of Edinburgh 
met cases of hemorrhage in the newly-born which he attributed to inflamma- 
tion of the vessels, arterial or venous, or both, from which the blood escaped. 
The inflammation, in his opinion, caused thickening and infiltration in the 
walls of the vessels, loss of tonicity, and consequently a patulous state. 
Simpson does not seem to refer in particular to the hemorrhage due to syph- 
ilis, but to that from other causes as well. Dr. Mracek, lecturer on syphilis 
in the University of Vienna, reported 19 cases of hemorrhagic syphilis in 
neonati.^ None of the mothers had undergone antisyphilitic treatment. One 
of the infants was born dead, while the others lived from half an hour to 
forty-eight hours. The capillaries, the vasa vasorum, the venules, and arte- 
rioles were filled with morbid products, having caused local troubles of circu- 
lation and sanguineous efl"usions. 

Among the first to draw attention to hemorrhagic syphilis of the newly- 
born was Behrends in 1883, whose opinions were based on clinical observa- 
tions. His views received support and confirmation from cases observed by 
Kassowitz, Dreahma, and Emilio Shutz. The last physician made careful 

1 Berlin, kiln. Woch., No. 46, p. 807, Nov. 15, 1886. 



UMBILICAL HEMORRHAGE. ]31 

microscopic examination of the vessels in infants who died of this hemor- 
rhage. Andronico also published an interesting paper on hemorrhagic syph- 
ilis of the newly-born.^ His observations justify, in his opinion, the state- 
ment that hemorrhages in syphilitic neonati are due not only to " diminished 
power of coagulation of the blood," but to a " vascular ectasis, particularly 
in the small cutaneous veins." 

Widerhofer,'^ remarking on hemorrhage in the syphilitic infant, attributes 
it to the blood dyscrasia. 

Bleeding from the navel also sometimes occurs as a symptom or complica- 
tion of jaundice. Writers who have collected records of this hemorrhage have 
remarked the frequent occurrence of the icteric hue both before and during 
the bleeding, even in those who do not present the history of syphilis. It is 
not improbable that in certain instances the jaundice is haematogenous, aris- 
ing from destruction of the red globules and liberation of the haematin — a 
not unusual result of a profound dyscrasia even when there is no syphilitic 
taint. In other instances the jaundice proceeds from the liver, and the bleed- 
ing occurs from the altered state of the blood, which is produced hy abnor- 
malities in the liver or its appendages. Thus in at least five of the cases of 
umbilical hemorrhage collated by Jenkins the marked jaundice which was 
present was found to be due to congenital occlusion of the common bile-duct, 
and of course all the bile secreted which did not remain in the liver entered 
the blood. The biliary acids in the blood probably diminish the amount of 
its fibrin and increase its fluidity. 

Poor health in the mother and impoverishment of her blood during gesta- 
tion, whether from chronic disease, as tuberculosis, or antihygienic conditions, 
also cause impoverishment and increase the fluidity of the blood, and there- 
fore act to a certain extent as a predisposing, if not as a direct, cause of the 
hemorrhage. Some have supposed that the excessive use of diluent drinks 
or alkalies by the mother during gestation also increases the fluidity of the 
blood of the foetus and renders it more liable to hemorrhages after its birth. 

In exceptional instances no adequate cause of the bleeding can be detected 
either in the child or the health of its parents. Thus in the Archives of 
Pediatrics for May, 1884, Dr. Seibert relates the case of an infant whose 
umbilical dressing and clothing were saturated with blood at the twentieth 
hour after birth. The bleeding was arrested, but it returned, and the child 
died. No coagula of blood occurred either in the pools or the saturated 
clothing. There was no history of haemophilia or syphilis in the parentage 
or lineage, and the child at birth was plump and apparently healthy, having 
no petechise, pemphigus, jaundice, or ecchymoses. The health of the mother 
had not, however, been good during gestation. 

Ordinarily, umbilical hemorrhage occurs without premonition, but occa- 
sionally it is preceded by jaundice. Jaundice was a prodromal symptom in 
41 of the 178 cases embraced in Jenkins's statistics, and, besides the icteric 
hue, constipation, clay-colored stools, deeply-tinged urine, etc. were recorded 
in some of the cases. Rarely colicky pains and vomiting precede the hemor- 
rhage. The blood oozes slowly or rapidly. It seldom escapes in a jet, even 
when its color shows that its source is more arterial than venous. 

Grandidier collated the histories of 202 cases, and the examination of 
these enables him to make the following statement : The hemorrhage often 
begins at night, so that it may continue a considerable time before it is 
detected. He also states that vomiting, colicky pains, somnolence, and espe- 
cially icterus, with constipation or clay-colored stools, sometimes occur. In 
135 of the cases embraced in Grandidier's statistics the hemorrhage occurred 

^ Arch, di Pat. Lifan., July, 1886. 

^ Allgem. Wien. med. Zeitung, No. 4, 1883. 



132 DISEASES OF THE NEW-BORN. 

in 38 before the fall of the cord, in 26 at the time of its separation, and in Tl 
at a later date. 

Prognosis. — This is unfavorable. Statistics show that 5 in every 6 
perish. The prognosis is most unfavorable when an obvious dyscrasia is 
present. Those who have jaundice or haemophilia with very few exceptions 
perish. Those are most likely to recover who have a healthy parentage, no 
obvious dyscrasia, and in whom the hemorrhage occurs late and is not pro- 
fuse. The average duration of the hemorrhage in 82 cases in Jenkins's col- 
lection was three and a half days, the minimum being only three hours. 
Death usually occurs from exhaustion. 

Treatment. — A compress of surgeon's lint or a sponge saturated with 
the liquor ferri subsulphatis should be firmly pressed over the umbilicus and 
retained by a bandage. If the bleeding do not cease, the umbilicus should 
be covered by a thick layer of plaster of Paris, supported by the hand until 
it hardens, and then retained in place by the bandage passing around the 
body. In the case related above, occurring in my own practice, this treat- 
ment arrested the bleeding from the navel, but it was followed by fatal 
intestinal hemorrhage. If the hemorrhage continue, the needles with lig- 
ature may be employed. Bouchut indeed states that this is the only effectual 
treatment. Two needles are passed through the umbilicus at right angles, 
and a waxed thread wound around each in the form of the figure 8. If the 
patient survive, the needles should be removed in four or five days and 
iodoform or a poultice applied. It is important, so far as time will permit, 
to treat the dyscrasia, and a laxative is often indicated, especially if constipa- 
tion be present. A laxative is useful for its effect on the hepatic circulation 
and as a derivative. Both Smith and Jenkins recommend calomel for this 
purpose. During the continuance of the hemorrhage four or five drops of 
brandy in breast milk frequently administered are useful as a stimulant. 



CHAPTER III. 

DISEASES OF THE NEW-BORN (Continued). 

Icterus Neonatorum. 

Icterus, or a yellowish discoloration of the skin, is common in the newly- 
born. It has even been said that in its mildest form it is present in the 
majority of infants, and it arises from a considerable number of anatomical 
and pathological conditions. It occurs in its worst and most intractable form 
when there is congenital obliteration of the bile-ducts ; it is believed to occur 
sometimes in the youngest infant from the same cause as that which produces 
the usual form of adult jaundice — to wit, catarrh of the duodenum extend- 
ing by propagation into the bile-ducts and narrowing or occluding their 
lumina. Congenital syphilis is another cause, the icterus being probably 
produced by the newly-formed connective tissue which compresses the bile- 
ducts. The modus operandi of the causes related above is easily understood, 
but a large proportion of the neonati who have the icteric hue in a slight or 
mild form do not appear sick, and fully recover after a few days. The cause 
in such cases is probably of a trivial nature, else it would produce a more 
profound impression on the system. West says of these mild cases in which 
there is no appreciable impairment of the health that the yellow tinge of the 



ICTERUS NEONATORUM. 133 

skin comes on about the third day, deepens for a day or two, and subsides 
gradually, ■• the bowels acting properly and the urine not being high-colored : 
though to this condition the name of jaundice has been applied, it is yet no 
real jaundice, but is merely the result of the changes which the blood in the 
over-congested skin is undergoing, the redness fading, as bruises fade, through 
shades of yellow into the genuine flesh color." A yellow coloring of the skin, 
the result of cutaneous hypergemia, is not accompanied by the diagnostic 
signs of true jaundice, such as a yellow conjunctiva, clay-colored stools, and 
biliary coloring matter in the urine. Inasmuch as the liver and other internal 
organs are not concerned in producing this form of icterus, West says it has 
been proposed to designate it by the term " local icterus." It would be 
interesting to ascertain in cases in which there is a deposit of pigment in the 
skin, while all the other organs, including the liver, are in their normal state 
and have their normal functional activity, whether there has been a cutaneous 
plethora due to late ligature of the cord. Zweifel states that the placenta 
before the uterus contracts after the expulsion of the child, and the cord is 
still beating, contains six ounces of blood, but if the cord have ceased to 
beat and the uterus be firmly contracted, half of this amount of blood, or 
three ounces, passes through the cord and augments to this extent the quan- 
tity of blood in the vessels of the foetus. Late ligature, therefore, when there 
is firm uterine contraction, increases the fulness of the blood-vessels in the 
child, and, according to Park, babies with distended blood-vessels exhibit a 
more intense jaundice. 

H. Quincke advances another and in some respects a plausible theory of 
the etiology of the common form of icterus neonatorum.^ He attributes the 
jaundice to the continued patency of the ducttis venostis. Henry Ashby 
says^ that in a minority of cases of jaundice of the new-born the clinical his- 
tory or post-mortem examinations reveal the cause, as when it arises from 
congenital defects, syphilitic hepatitis or cirrhosis, septicaemia or haemaglo- 
binuria. But the usual form of infantile jaundice, which begins on the 
second or third day, and commonly ends favorably, Ashby states, has nothing 
in common with the above fatal forms. He does not accept West's and 
Murchison's theory of a merely cutaneous icterus, and believes that Quincke's 
theory is the most plausible yet presented for consideration. The ductus 
venosus normally closes between the second and fifth days after birth, but 
if it remain pervious and the circulation from any cause be retarded, bile, 
according to the above theory, enters the branches of the portal vein and 
finds its way into the general circulation through the ductus venosus. In 
one case, says Ashby, an infant had jaundice from the second to the eleventh 
day, and at the autopsy the ductus venosus was large enough to admit an 
ordinary director. This theory also comports with the fact that feeble 
infants are more liable to become jaundiced than the robust, for those vas- 
cular canals which pertain to the foetal state and are obliterated after birth 
are more likely to remain a longer time pervious in the feeble than the 
robust. 

Dr. Alois Epstein^ made many experiments in order to determine whether 
bile-pigment occurs in the urine of icteric newly-born infants. He agitated 
the urine with lime-water, filtered it with alcohol, and added sulphuric acid. 
If bile-pigment be present a green color results. He discovered in the urine 
a pigment in the crystalline or amorphous state, and of a yellow or yellowish- 
red color. It occurred in the various forms of tufted needles or small tables, 

^ Archiv fiir experimentelle Pafhologie vnd Pharmakologie, xix. 1 and 2. 
^ Loncl. JlecJ. Times and Gnz.. April 25, 1885. 

^ " Ueber die Gelbsucht bei ISeugeboren Kindern/' Sammlung klinischer Vortrdge, 
No. 80, 1880. 



134 DISEASES OF THE NEW-BORN. 

yellowish or brownish, and in yellowish-red amorphous granulations. Epstein 
was able to distinguish by chemical reactions this pigment from uric acid and 
the urates. On further investigation he states that he found this pigment in 
all the organs, abundantly in the kidneys, and also in the blood. Does this 
pigment have an hepatic or hasmic origin ? Epstein is led by his investiga- 
tions to believe that this crystalline or amorphous pigment results from 
changes occurring in the blood, and probably from the liberation of the 
coloring matter by the destruction of the red corpuscles, which Neumann, 
Kolliker, Denis, Hayem, and others have shown to occur so abundantly in 
the neonati. 

Epstein believes that any marked impairment of the important functions 
in the system tends to increase the destruction of the red corpuscles, the con- 
sequent release of its coloring matter, and the formation of the crystalline or 
amorphous pigment described above, which in icterus escapes into the tissues. 
Marked impairment of respiration, circulation, and calorification, artificial 
alimentation, prematurity, protracted and difficult birth, taking cold, and 
similar agencies, in proportion as they impair the general health and pro- 
duce perturbation in the system, increase the destruction of red corpuscles, 
and thereby act as causes of icterus. Epstein also mentions the well-known 
fact that the children of parents who have grave constitutional diseases or 
live under bad hygienic conditions are especially liable to become icteric, and 
that septic infection is an important cause of those alterations in the blood 
which give rise to icterus. 

The peculiar character of the blood of the newly-born is believed by good 
observers who have investigated this subject to predispose to the occurrence 
of jaundice. According to Hofmeier, the red blood-corpuscles in the neonati 
are more spherical than in adults, and do not show a tendency to form rou- 
leaux. The white corpuscles are often more numerous than in adults; they 
are viscid, deliquescent, easily destroyed, and have a tendency to aggregate 
in rouleaux. The investigations of Ponfick and Silbermann^ show that the 
red corpuscles of the new-born readily part with their coloring matter, the 
haemaglobin, under disturbing agencies, such as syphilis, burns, taking cold, 
injudicious nursery management, and even by the action of certain medicinal 
agents, as glycerin and pyrogallic acid. The red corpuscles, which have lost 
their coloring matter by its transference to the plasma, either disintegrate 
and disappear, or they appear under the microscope as pale rings which have 
been designated shadows. This transference of the coloring matter from the 
red corpuscles to the liquor sanguinis, and the disintegration of red corpuscles, 
which characterize the first few days of infant life, lead to an increase of haema- 
globin in the plasma (hsemaglobinhasmia) and of fibrin ferment. Silbermann 
summarizes his views, derived from an examination of the character of the 
blood and the blood-changes occurring in the newly-born, as follows : " The 
blood of the newly-born holds corpuscles which vary greatly in size, and also 
the so-called shadows : it is richer in fibrin ferment than the blood of adults ; 
these peculiarities are due to the liberation of haemaglobin and its transfer 
into the plasma ; the richness in fibrin ferment of the blood of the newly- 
born predisposes to disease ; all disease-processes in the newly-born which 
involve great destruction of the albumen in the circulation are especially dan- 
gerous to life." These investigations relating to the blood will aid to an 
understanding of the views of Silbermann regarding icterus. 

Dr. Silbermann concludes^ an elaborate paper on icterus neonati with the 
following aphorisms : " 1st. Icterus of the newly-born is an icterus of absorp- 

^ '•' Zur Hamatologie der Neugeborenen," Jahrbuch fur Kinderheilkunde, 1887. 
^ Archiv far Kinderheilkunde, 1887. 



ICTERUS NEONATORUM. 135 

lion. 2d. The biliary engorgement has its seat in the biliary capillaries and 
the interlobular bile-ducts, which are compressed by the dilated branches of 
the portal vein and the capillary blood-vessels of the liver. 3d. This engorge- 
ment in the vessels is effected by the change in the circulation of the liver which 
occurs soon after birth, and is one of the indications of a general change in 
the blood-plasma. 4th. This change, which is induced by the destruction of 
many blood-corpuscles soon after birth, consists of a kind of blood-fermenta- 
tion. 5th. The more feeble the infant the more intense will be the icterus, 
for in such a child the destruction of corpuscles, and the consequent blood- 
changes, will be much more decided than in a vigorous child. 6th. As the 
consequence of the destruction of so many red corpuscles there is abundant 
material for the formation of biliary coloring matter, and under the influence 
of the fermentation-process alluded to this accumulates in considerable quan- 
tity." Therefore, according to this theory, free coloring matter in the blood, 
derived from the abundant destruction of the red corpuscles which attends 
the first days of infancy, occurs in such quantity that it cannot be disposed 
of in the biliary secretion or otherwise eliminated, and is deposited in the tis- 
sues, causing the icteric hue. 

Birch-Hirschfeld ^ attributes icterus of the new-born to oedema of the 
capsule of Glisson, and consequent compression of the bile-ducts. This 
cedema he believes is due to diminution of pressure in the portal system 
consequent on section of the cord. 

That feebleness, insanitary conditions, and exposure are a cause of jaun- 
dice, however they may act to produce such a result, is shown by many 
observations. West, as we have stated above, describes a local or cutaneous 
icterus resulting from plethora of the skin, and having no special interest or 
importance, and a systemic or general icterus, which he states " does not affect 
perfectly healthy children who have been born at the full time, have been 
nourished exclusively at the mother's breast, and been sheltered from cold 
without being overburdened with clothing or confined in a vitiated atmo- 
sphere." In corroboration of this statement lie alludes to the fact that in 
the Dublin Lying-in Hospital, where the utmost care is bestowed on the 
foundlings, icterus is rare, while it is so common in the Foundling Hos- 
pital of Paris that few escape. In the latter institution, as compared with 
the former, the exposures are much greater and the conditions as regards 
hygiene are greatly inferior. 

M. Bouchut says that icterus is observed in 80 to 90 per cent, of the 
new-born ; that Levret, Breschet, Billard, and Valleix regard it as the result 
of ecchymosis of the skin following congestion — an opinion which he con- 
siders erroneous. He believes that it almost always results iTom a mild or 
severe hepatitis consequent on ligature of the cord. The ligature, he says, 
produces a mild inflammation which is propagated to the liver and causes 
obstruction of the bile-ducts. In his articles on hepatitis of the new-born 
he repeats his belief in this theory. 

The obvious inference from the above resume of opinions is that icterus 
neonatorum results from different causes in different instances, and that it is 
a mild or grave disease according to its etiology. The various causes admit 
of classification in two groups : 1st, the haematogenous ; 2d, the hepatoge- 
nous. The hsematogenous theory, which attributes the common form of 
icterus of the newly-born to the destruction of the red blood-corpuscles in 
the first days of life, and the escape of the coloring matter into the circulation, 
is advocated by such men as Billard, Virchow, Breschet, Porak, Violet, and 
Epstein. The hepatogenous theory has also advocates of equal reputation. 
The etiology of this disease certainly requires further investigation, and when 

^ Virchow's Arch., 1882, Band Ixxxvii. 



136 BISEASES OF THE NEW-BORN. 

it is better understood it will probably be seen tbat distinct pathological 
states in the newly-born have been described under the term "icterus." 

Prognosis. — This depends on the nature of the cause as well as the 
present state of the infant. If the cause be susceptible of removal, as in 
the common mild form of icterus, a favorable prognosis is justified. The 
must unfavorable cases are those in which there is absence of the biliary 
ducts or their permanent occlusion. In severe forms of the disease in which 
the connective tissue, the secretions, and transuded serum have the yellow 
hue the prognosis should be guarded. 

The common mild form of icterus, appearing on the second or third day 
after birth, disappears or is scarcely appreciable at the close of the second 
week. Severe icterus, continuing longer without any abatement in its inten- 
sity, is due as a rule to permanent anatomical conditions which prevent the 
flow of bile into the intestine, and is probably incurable. In these cases 
the stools remain clay-colored, the icterus increases, and vomiting may 
occur. 

The TREATMENT is simple, and to a considerable extent expectant. Gen- 
tle friction over the liver may perhaps in some cases aid in removing the 
obstructive disease in the bile-ducts. The use of hydrarg. cum creta in 
small doses, as recommended by AVest, is of doubtful efficacy. It is evident 
that preventive measures are more important and more efficacious than the 
curative, since every measure which promotes a healthy parentage and the 
health and robustness of the infant tends to diminish the frequency of this 
disease. Those who, like Porak, believe that congestion of the skin at birth 
is a common cause of the simple form of jaundice recommend an early ligature 
of the cord, when the umbilical arteries are still beating or have just ceased 
to beat, since when the arteries are beating an equilibrium is maintained in 
the circulation, whereas in a late ligature, when the uterus is firmly con- 
tracted and the arteries have for some time ceased to beat, a plethoric state 
of the vessels is more likely to occur. 

Sepsis of the New-born.^ 

The manner in which sepsis or septicaemia occurs is sometimes obscure. 
Leube in 1878 relates two cases'^ in which the examination failed to disclose 
the source or mode of infection. He designates such cases cryptogenetic, 
expressive of the unknown or occult origin. Wunderlich and Schiitzenberger 
allude to similar cases. But in sepsis of the newly-born it is the common 
and apparently correct belief that the poison of sepsis usually enters the 
system at the umbilicus. The cases which I am about to relate are in har- 
mony with this theory. 

It is not my intention to discuss the nature of the septic poison, but there 
can be little doubt, from the exariiinations which were made, that in the fol- 
lowing cases it consisted of microbes and the ptomaines or chemical agents 
produced by microbic action. 

Cases of sepsis of the newly-born may be conveniently classified as 
follows : 

First Group. — Gases of umhilical jjhlegmon., which is a local sepsis, the 
poison entering the system from an umbilical sore, and being conveyed by the 
lymphatics. 

The New York Infant Asylum at Sixty-first street and Tenth avenue has, 
during the twenty-three years of its existence, been remarkably free from 

^ Read before the Psediatric Section of the New York Academy of Medicine, Medi- 
cal News, Sept. 8, 1888. 

'•^ Deutsch. Archiv far klin. Med. 



SEPSIS OF THE yEW-BORy. 137 

contagious and infectious diseases, but since September 1, 1887, seven cases, 
in which either local or systemic sepsis was diagnosticated, occurred in new- 
born infants in the maternity ward of this institution. It is proper to state 
that at the same time diphtheria was epidemic in the asylum, and that five 
of the newly-born infants had diphtheria, the pseudo-membrane appearing in 
its usual situation on the pharyngeal, nasal, and laryngo-tracheal surfaces, 
and, in one or two of the patients, also lining the oesophagus. 31oreover, 
two of the five infants with diphtheria had umbilical phlegmon of a few 
days' duration when the diphtheritic exudate appeared upon the faucial 
surface. 

The question is therefore a proper one. whether in these two cases the 
phlegmons were a local manifestation of diphtheria, or whether the umbili- 
cal phlegmon and diphtheria were distinct diseases having a different microbic 
origin. 

Case 1. — Victor M was born, after normal labor, on January, 5, 1888, and 

the umbilicus was dressed with borated cotton. The mother did well, and was 
able to leave her bed on the seventh or eighth day. Nothing unusual was noticed 
in the infant until January lltli, when a little suppuration was observed in the 
umbilical fossa at or around the point of attachment of the cord, and on exami- 
nation the walls of the umbilicus were found thickened and indurated. The 
appearance indicated the commencement of an umbilical phlegmon, and the skin 
covering it was red as in erysipelas. The phlegmon extended in area until Jan- 
uary 14th, when the thickening and infiltration reached to the distance of about 
one' and a half inches in every direction from the umbilicus, so that the form of 
the phlegmon was circular or wheel-shape. Its thickness or depth near the 
umbilicus was perhaps three-fourths of an inch, but near its margin the thicken- 
ing and infiltration were less. The pulse on the 13th varied from 132 to 144, and 
the rectal temperature was 101. 8'^. 

The case was carefully watched by Drs. Davis and Cook, the resident physi- 
cians, whose records I employ, and the faucial surface was daily inspected by 
them. On January 14th, the baby being nine days old, they observed for the 
first time the grayish-white exudate of diphtheria on each side of the fauces, and 
a day or two later also upon the Schneiderian surface, so closing the nostrils that 
respiration through them was impossible. The baby, on attempting to draw the 
nipple, became cyanotic and was obliged to relinquish its hold. During the 14th 
and 15th the temperature fell to 98.5^ and 98°, the pulse was very feeble and too 
rapid to be counted accurately, and the respiration varied from 24 to 48. Death 
occurred on the 15th at the age of ten days. 

The autopsy revealed a diphtheritic pseudo-membrane upon the faucial sur- 
face on both sides, extending downward, so as to cover both surfaces of the 
epiglottis, the entrance of the larynx, and the laryngeal surface, completely con- 
cealing the vocal cords and the portion of the larynx above them. The trachea 
and bronchial tubes were free from the exudate. The lungs in nearly every part 
were thickly mottled with points of extravasated blood, and less abundant extrav- 
asations w^ere observed in and upon other organs. The umbilical phlegmon, 
removed entire, and in a frozen state from the intensity of the cold in the dead- 
house, was sent to the laboratory of the College of Plwsicians and Surgeons, 
where it was carefully examined by Dr. Prudden. He reports that the umbilical 
vessels were in their normal state, showing no evidence of disease, except the 
mouth of the umbilical vein or that portion of the vein which was next to and 
in immediate relation with the umbilicus. Plugging the mouth of the vein and 
extending a few lines along the lumen of this vessel was a thrombus or blood- 
clot, from which Dr. Prudden was able to obtain cultures, and in the culture-bed 
two forms of cocci were developed — to wit, the staphylococcus pyogenes aureus, 
occurring in the usual form in groups, and the streptococcus pyogenes, producing 
beautiful and delicate chains. The portion of the vein enclosing the thrombus 
or clot had preserved its integrity, so that the clot was entirely distinct from the 
phlegmon which covered the vein. It did not seem possible that microbes, 
ptomaines, or elements of the blood could pass from one to the other, on account 
of the firm coats of the vein which Avere interposed between them. 



138 BISEASES OF THE NEW-BORN. 

Portions of the phlegmon placed in culture media, developed the same forms 
of cocci as those produced from the clot that plugged the mouth of the vein. 
We infer that the cocci were the septic agents, since no other cause of the sepsis 
was discovered, and that they were received from the umbilical sore. Some 
entered the thrombus, and others, taken up by lymphatics, entered the tissues 
which surrounded the umbilicus and gave rise to the phlegmonous inflammation. 

It is easy to understand how micro-organisms may enter the umbilical 
vein after the fall of the cord, when there may not be complete closure of 
the mouth of the vessel. But it can scarcely be doubted that in the above 
case, as well as in cases which I am about to relate, the septic infection took 
place through the raw and denuded surface of the umbilical fossa, the lym- 
phatics being the carriers of the poison. We know how frequently granu- 
lations sprout out from the umbilicus of the new-born, and wherever there is 
a surface denuded of cuticle from which these may arise there is a surface 
from which microbes or toxic agents may be absorbed. The umbilicus, too, 
is a receptacle in which microbes, conveyed in the floating dust of an apart- 
ment, in foul water used for bathing, in dirty sponges, or abdominal binders 
or umbilical dressings, would be likely to lodge. M. Bouehut, in his remarks 
on the fall of the umbilical cord, says : " Cords voluminous, soft and plump, 
dry slowly and often suppurate at their base before they fall (les cordons 
volumineux, mpus et gras, se dessechent lentement et suppurent souvent 
a leur base avant de tomber)."^ With conditions so favorable for septic 
infection it is perhaps surprising that it does not more frequently occur, 
especially in hospital or asylum wards. 

The patient whose case I have related evidently had systemic infection 
in addition to the local septic infection in the phlegmon. The numerous 
points of extravasated blood in the lungs and elsewhere showed this. But 
doubt must arise whether this general infection occurred from the phlegmon, 
in which there was intense hypersemia and an active circulation, as shown by 
the inflammatory redness of the cuticle, or whether it resulted from and was 
connected with the diphtheria. But we will relate cases of systemic infec- 
tion in which there was no diphtheria and in which the septic agent or agents 
entered the system through the umbilicus. 

The volume of the Transactioim of the London Pathological Society for 
1879 contains an able and elaborate report of the committee appointed by 
that society to investigate pyaemia, septicaemia, and purulent infection. 
Their report is based on the examination of the records of 156 cases occur- 
ring in the London hospitals, and it throws light on the cause of hemorrhagic 
extravasations occurring in cases of septic infection of the system. They 
remark : " On microscopical examination of different organs, micrococci were 
found in all, or at least in some, of the viscera. They were nearly all in the 
blood-vessels, completely plugging the capillaries ; in masses which sometimes 
produced varicosities, or even rupture of the vessels, and extended into the 
contiguous tissues."^ 

Case 2. — Hilda M , born February 28, 1888, was plump and robust, weigh- 
ing eight pounds and seven ounces. The mother appeared to be well until March 
3d, when she had fever and symptoms which were apparently due to pelvic cel- 
lulitis, probably of septic origin. The infant was fretful on March 3d and 4th, 
and on March 5th a small ulcer was observed in the umbilical fossa. The skin 
surrounding the umbilicus, over an area the size of a silver dollar, had a deep- 
red color, and the tissues underneath, constituting the abdominal walls, were 
infiltrated and thickened. The phlegmon gradually extended in every direc- 
tion from the umbilicus, so that on March 6th it nearly reached the ensiform 
cartilage above and the pelvis below. The fauces had been inspected daily, and 

^ Traite pratique des Maladies des Nouveau-nes, etc. 
2 ^,,^Y. 3fed. Jour., January 24, 1880. 



SEPSIS OF THE NEW-BOBN. 139 

at 5 P. M., March 6th, the grayish-white exudate of diphtheria was observed 
for the first time, covering the tonsillar portion of the fauces on each side. On 
March 7th the exudate had increased, the cry was hoarse, the fingers livid at 
times, and fluid regurgitated through the nostrils. The phlegmon occupied 
nearly the entire abdominal walls anteriorly, March 8th, surface cyanotic ; res- 
piration labored, and at times accompanied by the expiratory moan ; a diphthe- 
ritic pseudo-membrane in the right nostril. Death occurred at 6.30 A. M., March 
9th, at the age of ten days, on the fourth or fifth day of the phlegmon and on the 
third day of the diphtheritic exudate upon the fauces. The rectal temperature 
varied from 99.8° to 102.8° until the last day, when it was subnormal, being 
96.6°; the pulse varied from 99 to 112, and the respiration from 40 to 60. Both 
the pulse and respiration gradually increased in frequency until death, this 
increase being probably largely due to the double pneumonia. The tincture 
of the chloride of iron in glycerin, brandy, and breast-milk were given inter- 
nally, iodoform and carbolized oil applied to the umbilicus, and antiseptic sprays 
employed for the fauces and nostrils. 

Prof. T. M. Prudden kindly consented to conduct the autopsy, which was 
made with sterilized instruments and under conditions designed to prevent 
access to the body of adventitious germs. The following are his notes: 

Autopsy. — The umbilical orifice was covered by a dry, brownish scab, beneath 
which was a small, rough-edged cavity containing a yellowish semi-solid mass. 
The abdominal wall, for about three centimetres around the umbilicus on all 
sides, was hard, thickened, and dusky red. A section through the abdominal 
wall in the line of the umbilicus showed that the wall was thickened to about 
1.5 centimetres immediately around the latter. 

Both the umbilical vein and the hypogastric arteries, to the distance of about 
1.3 centimetres from their attachment to the abdominal Avail, were much thick- 
ened, red and hard, and their inner layers were converted into a soft, yellowish, 
friable material. Beyond this point all of these vessels were filled with blood- 
clots and appeared healthy. There was no peritonitis, and all of the abdominal 
organs were normal. 

The heart was normal. The pharynx, larynx, and trachea showed soft, red- 
dish friable patches of diphtheritic membrane partially covering their free sur- 
faces. This membrane did not extend into the bronchi. The lungs exhibited 
broncho-pneumonia in both lower lobes, with considerable consolidation. 

The microscopical examination of the parts about the umbilicus showed that 
at the point of attachment of the cord was a small pus-cavity whose walls were 
infiltrated with small spheroidal cells, with a few rod-like bacteria and with large 
numbers of spheroidal bacteria. Similar spheroidal bacteria were found in the 
purulent detritus contained in the cavity as well as within the lumina, and infil- 
trating the walls of the adjacent ends of the umbilical vein and the hypogastric 
arteries. 

The tissues of the abdominal walls about the umbilicus were infiltrated with 
serum, fibrin, and a moderate amount of pus. Spheroidal bacteria were rather 
scantily scattered in the lymph-spaces of the swollen tissues, being most abun- 
dant near the umbilical vessels. 

Biological examination of the contents of the inflamed portion of the umbili- 
cal vessel showed the presence of several species of bacteria. The species which 
was by far the most abundant was readily identified as the staphylococcus pyo- 
genes aureus. 

The anatomical diagnosis, then, is diphtheria of the pharynx, larynx, and 
trachea, with double broncho-pneumonia, localized septic inflammation of the 
umbilical vein and hyj30gastric arteries and of the abdominal wall surrounding 
them. 

As the evidence of local infection is so great, it seemed desirable to gain some 
data as' to the purity of the air in the wards. Accordingly, such analyses as time 
permitted were made by Dr. T. M. Cheeseman, Jr., who presented the following 
report : " A biological examination of the air in the lying-in ward of the New 
York Infant Asylum, made on March 7, 1888, showed a very large number of 
living bacteria of many different kinds. Among them the staphylococcus pyo- 
genes aureus was of frequent occurrence. A second examination, made imme- 
diately after the usual sulphur disinfection, showed a large number of living 
germs." 



140 DISEASES OF THE NEW-BORN. 

Case 3. — Janse J , born January 3, ]888, was wet-nursed by its mother^ 

and apparently did well until January 16th, when the attention of the resident 
physician was directed to it, and an umbilical phlegmon was discovered as large 
as a twenty-five cent piece, the skin covering it being intensely red ; temperature 
98.5°. The dressing, after the discovery of the phlegmon, consisted in dusting 
with iodoform and the application of carbolized oil (one part of carbolic acid to 
twenty-five of sweet oil). January 17th, phlegmon not extending and its surface 
less red. The redness, thickening, and infiltration gradually abated, and on Jan- 
uary 21st the patient was removed from quarantine. In this case there was no 
record of an umbilical sore; the fauces remained normal, so that the diagnosis 
of diphtheria was excluded. The mother continued well. 

Case 4. — George C was born in the maternity ward January 14th. On 

January 25th the nurse observed a small vesicle upon the border of the umbili- 
cus, and removed the cuticle covering it. Some hours afterward the attention 
of the resident physician. Dr. Davis, was called to it, wdio found thickening and 
infiltration of the umbilical wall, most marked on the side which had been 
occupied by the vesicle. The same treatment was employed as in Case 3. The 
records of January 26th and 27th state that the redness and infiltration are abat- 
ing, and on the 29th the umbilicus had returned to the normal state. 

Case 5. — John S , born October 14, 1887, the mother being a healthy 

primipara. The child was well developed at birth, weighing nine pounds and 
four ounces. The cord fell on the sixth day, and a small ulcer with indurated 
edges was observed in the umbilical fossa at the point of attachment of the cord. 
The induration in and around the umbilicus increased slowly until the ninth 
day. On the ninth day the child was restless, and on examination the ulcer was 
found enlarged and surrounded by a zone of inflamed tissue half an inch in 
width. The inflammation, accompanied by the usual infiltration and swelling, 
gradually extended, so that on the 15th the diameter of the inflamed area was 
two inches. The ulcer had also increased. On the twentieth day after birth the 
ulcer had attained the diameter of two inches and the depth of three-eighths of 
an inch, but the induration had begun to abate. From this time improvement 
was progressive, and no notes were taken after the twenty-fourth day. The rectal 
temperature, ascertained each day from the ninth to the twenty-fourth day, varied 
from the normal to 102°. During the active period of the phlegmon it was 
usually from 100° to 101.5°, and the emaciation was progressive, the loss of 
weight being estimated at two pounds. The treatment consisted in dusting with 
iodoform and the use of a compress of absorbent cotton soaked with a solution 
of carbolic acid. During the second week, under the advice of the attending 
physician. Dr. George B. Fowler, calomel was also dusted on the sore. On the 
twenty-fourth day the infant was removed to the Post-Graduate School, and its 
subsequent history is unknown. The mother had no unfavorable symptom. 

Case 6.— Joseph D , born October 22, 1887, well developed, weighing 

seven pounds thirteen ounces. The cord fell on the eighth day, leaving a small 
ulcer at its point of attachment with an indurated border. Two days later, the 
tenth day after birth, the ulcer had increased slightly, being one-quarter of an 
inch in diameter. The surrounding tissues to the distance of one inch were 
thickened and indurated from inflammation. At no time was the temperature 
above 99.1°, and the child, though restless, nursed well. The tumefaction and 
hardness surrounding the umbilicus remained about the same until the sixteenth 
day, after which they gradually abated. The ulcer had healed at the end of the 
fourth week. The mother on^the third day after confinement had elevation of 
temperature which continued four days ; and six weeks after the birth of the 
child she had diphtheria in the usual form. During the same month — October — 
twenty-seven obstetrical cases were under observation, but all except this patient 
convalesced without any unfavorable symptom. 

Second Group. — Cases in which the septic poison prohahli/ entered the 
system through the umbilical vein. 

Case 1. — In May, 1884, an infant died of sepsis at the New York Infant 
Asylum at the age of fifteen days. It was apparently well until about the close 
of the first week, when the umbilicus was observed to be raw^, and a slight oozing 
of a puriform liquid occurred from it. During the second week the abdomen was 



SEPSIS OF THE NEW-BORN. 141 

hard and tender, and peritonitis was diagnosticated. The cord fell on the seventh 
day. During the second week the abdomen was apparently painful ; the tem- 
perature three days before death was 100.6°, and two days before death 102.4°. 
Examination of the chest gave a negative result. The post-mortem examination 
was made by Dr. W. H. Welch, now professor of pathology in Johns Hopkins 
University. The abdomen contained six ounces of turbid serum with flakes of 
fibrin. The portion of the peritoneum covering the umbilical vein and along the 
under surface of the liver, especially at the transverse fissure, was covered with 
fibrin, but the peritoneum generally did not exhibit any notable hypersemic or 
inflammatory appearance. Lymphatic vessels filled with purulent-appearing 
substance could be seen in the under surface of the diaphragm, showing in what 
way septic infection extends along the lymphatics. The lymphatics of the dia- 
phragm open upon the pleural surface, and it is probable, had the patient lived 
longer, that septic pleuritis, perhaps on both sides, would have occurred. The 
umbilical vein was filled from the umbilicus to the transverse fissure of the liver 
with a grayish softened detritus consisting of broken-down thrombi with a con- 
siderable proportion of pus. Softened thrombi could be traced the entire length 
of the umbilical vein, the walls of which were thickened and infiltrated from 
inflammation. No thrombi were seen in the portal vein or vena cava ; the peri- 
cardium contained more than the normal amount of serum with flakes of fibrin ; 
hemorrhagic points were observed in the posterior portions of the lungs under 
the endocardial surface, under the peritoneal coverings of the kidneys and mucous 
covering of their calices. The mother did well, giving no evidence of disease of 
any kind. 

Case 2. — This infant, born in the New York Infant Asylum, the date not 
being given, was well developed at birth, weighing eight pounds six ounces. 
When four or five days old it became feverish, the temperature rising to 104.6°. 
The cord separated at the usual time, and the umbilicus seemed healthy. At 
the age of two weeks an abscess appeared upon the scalp, another upon the back, 
and another upon the nates, which raised the suspicion of septic poisoning. At 
the age of four weeks orchitis on one side occurred, which continued three weeks, 
when it abated. When the child was two months old a prominence appeared 
about half an inch above the umbilicus, which Dr. Parker, the resident physician, 
punctured, and bile flowed from the incision. Subsequently the incision closed, 
and bile flowed from the umbilicus, and continued to flow until death, which 
occurred, in a state of much emaciation and weakness, at the age of eight 
months. 

At the autopsy, made by Prof. Welch, remains of old abscesses were found 
upon the trunk and extremities, and an abscess holding four drachms of pus was 
found over the occipital bone. Underneath the abscess the bone was carious 
and the dura mater thickened. The umbilical vein was much larger than nor- 
mal, its walls being infiltrated and thickened, and its lumen of about twice its 
usual diameter. It contained thickened bile. One of the branches of the vein, 
traced into the liver, opened into an abscess the size of a walnut, which contained 
thickened pus with bile. The abscess was in the right lobe near its posterior 
border. The mother remained well. 

Case 3. — Lizzie C , born September 21, 1887, robust, weighing eight 

pounds, seemed well, taking the breast and having normal evacuations, until 
September 28th, when she became restless and refused the breast. Her tempera- 
ture, rectal, was 101.4°, and her respiration was accelerated and accompanied by 
the expiratory moan. September 20th, temperature 103.6° ; respiration acceler- 
ated and painful and abdomen distended ; no cough. The diagnosis of perito- 
nitis, probably of septic origin, was made, but the umbilicus was of usual 
appearance, and the desiccation and fall of the cord seemed normal. The ele- 
vation of temperature, even to 104.4°, the distension of abdomen, and the hurried 
respiration with expiratory moan continued until death, which occurred Sep- 
tember 30th. 

At the autopsy three ounces of sero-purulent liquid containing flakes of fibrin 
escaped from the peritoneal cavity. All the abdominal organs Avere covered by 
a fibrinous exudation, the intestines being matted together by it. The umbilical 
vein was pervious ; it contained clots of blood and dirty-looking pus, but the 
umbilicus was apparently normal. A segment of the aortic valve was thickened 
and rigid, and attached to it was a fibrinous mass. The appearance indicated an 



142 DISEASES OF THE NEW-BO EN. 

endocarditis of slight extent. Under the microscope the walls of the umbilical 
vein presented their normal appearance, but its dirty-looking and disintegrating 
contents probably contained septic matter. The "hepatic cells exhibited the 
peculiar cloudiness observed in protracted febrile diseases. Otherwise the organs 
seemed healthy. In this case also the mother remained well. 

Case 4.— A. B — — , born January 22, 1868 : father healthy, but mother 
strumous, though in good health during her gestation. The infant, born after 
an easy labor, was apparently well at birth and it had sufficient breast-milk. 
When it was thirteen days old I was requested to visit it, as it had not been doing 
well, and I found it suffering from subcutaneous abscesses. Abscesses had 
occurred upon both legs, in the chest- walls of the right mammary region, in and 
around the metatarso-phalangeal articulations of one foot, and over both knee- 
joints. The child had fever, but its respiration was good until February 8th^ 
when it suddenly had a severe attack of dyspnoea, which continued until death, 
ten hours subsequently. On the following day Dr. Charles A. Leale and myself 
made the autopsy. The body was moderately emaciated. About one ounce of 
pus escaped from the right knee-joint. Pus was also found in the joint of the 
great toe on one side, and about two ounces in an abscess under the right pectoral 
muscle. A thin layer of tissue constituted the internal wall of the abscess, so 
that had life been prolonged a few days it would probably have broken through 
into the pleural cavity. The right lung was completely collapsed, and the pleura 
lining this lung, as well as that lining the thoracic walls on the same side, was 
covered by a fibrinous exudation. The left lung contained the normal, or per- 
haps more than normal, amount of air, so that it filled the pleural cavity, but there 
was a small amount of fibrinous exudate upon the parietal pleura in this cavity. 

The trachea and lungs attached were removed, and on practising insufflation 
of these organs, air escaped from three openings in the posterior part of the right 
lung. These openings, through which air had passed into the pleural cavity, caus- 
ing collapse of the entire lung, were found on examination to have been produced 
by small abscesses in the tissue of the lung near its posterior surface. By the rup- 
ture of these abscesses the pus which they contained escaped into the pleural cav- 
ity, producing intense general pleuritis and pneumothorax. Numerous minute 
abscesses were found in both lungs, but only the three alluded to had been rup- 
tured. It seemed certain that had the patient lived longer other abscesses would 
have ruptured. 

Case 5. — In the following case bacteria were found making their way along 
the umbilical vein at a distance from the umbilicus, and also in the tissues 
involved in the umbilical phlegmon. Those in the phlegmon were apparently 
derived from the umbilicus and conveyed by the lymphatics. This case, there- 
fore, might be placed in the first group as well as the second : 

Anne was born in the New York Foundling Asylum on May 18, 1888. 

A few days after birth, and before the cord dropped, the umbilicus was observed 
to be foul from secretion or exudation in it, indicating a sore at the base of the 
fossa. On the seventh day an umbilical phlegmon was noticed, small and con- 
fined to the umbilical walls. Three white patches were also observed on the roof 
of the palate near the velum, not raised and apparently not diphtheritic, resem- 
bling superficial ulcers. All the infants born in the maternity ward of the Found- 
ling Asylum receive Credo's treatment, designed to prevent purulent conjunctiv- 
itis, one drop of a 2 per cent, solution of nitrate of silver being instilled between 
the eyelids of each eye. Although this child was thus treated, she had a pretty 
active purulent conjunctivitis of the left eye, to which our attention was now 
called for the first time on the seventh day. Crede's treatment was immediately 
reapplied to this eye, one drop being introduced between the lids. This was fol- 
lowed by the corrosive-sublimate treatment recommended by the late Prof. Sam- 
uel D. Gross. A solution of the sublimate, two grains to the pint, was dropped 
between the lids every hour to two or three hours, four or five drops being used 
each time. The conjunctivitis rapidly abated, and in less than a week had nearly 
or quite disappeared. But the phlegmon presented a very angry appearance, and 
the umbilical walls were greatly swollen, red, and denuded of cuticle. The 
inflamed area had a diameter of about four inches, with the umbilicus at the 
centre. Iodoform and carbolized oil were applied to the umbilicus and iron and 
stimulants given internally. The rectal temperature, taken May 26th, was 98°.. 
Death occurred May 27th. 



SEPSIS OF THE NEW-BORN: 143 

Autopsy, by Dr. W. P. Northrup, curator, thirteen hours after death. — Body 
well nourished ; no rigor mortis ; no external lesion except the umbilical ; the 
phlegmon definitely outlined and hard, its central half brown and dry ; the infil- 
trated abdominal wall had twice its normal thickness ; peritoneal surface of phleg- 
mon congested and adherent to omentum ; from this point to the transverse colon 
was a leash of dilated vessels, one inch in width and three or four inches in 
length ; peritoneum injected, and a few petechias observed in the parietal layer 
and the mesentery; mesentery deeply injected; liver and spleen normal; kid- 
neys soft and flabby ; points of hemorrhagic pneumonia in all the pulmonary 
lobes ; abundant tenacious mucus covering the surface of the stomach and intense 
injection, showing acute gastritis ; cerebral pia mater finely injected, but without 
exudation ; brain normal. Diagnosis : umbilical phlegmon, peritonitis, acute 
gastritis, hemorrhagic pneumonia. 

Microscopical and Biological Examination, by Prof. Prudden at the Laboratory 
of the College of Physicians and Surgeons. — The small ragged cavity at the 
umbilicus contained a moderate amount of pus, cell-detritus, and enormous num- 
bers of bacteria of various forms, the spheroidal form predominating. The tis- 
sues of the abdominal wall about the umbilicus were infiltrated with fluid, fibrin, 
and pus ; scattered about in this exudation-mass were small spheroidal bacteria. 
The hypogastric arteries and the umbilical vein were plugged with clots extend- 
ing from one-half to three-quarters of an inch from their origin ; their walls were 
greatly thickened by infiltration with inflammatory exudate. Both in the lumina 
of these vessels, along the sides of the clots, and in the lymph-spaces in their 
walls were enormous numbers of small spheroidal bacteria. These bacteria were 
present in the umbilical vein beyond the limits of the clots in the direction of 
the liver. 

The kidneys showed moderate parenchymatous degeneration. The consoli- 
dated areas in the lungs were due to a nearly complete filling of the air-spaces 
and the smaller bronchi with blood. 

Cultures made from the inflamed tissue about the umbilicus and from the 
edges of the sloughing cavity showed several species of bacteria common in the 
air and in the feces of children. In addition to these the staphylococcus py- 
ogenes aureus w^as present in large numbers. A set of cultures from the inside 
of the umbilical vein, at a little distance from the sloughing cavity, revealed the 
presence of staphylococcus pyogenes aureus and streptococcus pyogenes, together 
with other forms. Cultures from the liver showed large numbers of staphylo- 
coccus pyogenes aureus, with considerable numbers of a stout bacillus similar to 
one abundant in the sloughing cavity. From the lung tissue from the consoli- 
dated regions enormous numbers of bacilli developed in a nearly pure culture, 
which corresponded in its biological characters to the bacterium lactis aerogenes 
of Escherich. 

Remarks. — This child would thus seem to have been the victim of infection 
with the ordinary "suppurative bacteria" and with feces. We infer that fecal 
matter in some way came in contact with the umbilicus. 

Third G-ROUP. — It seems prohahle that in exceptional instances the sejjtic 
poison in sepsis of the newly-horn is received in other ways or other channels 
than at the umhilicus. 

If sepsis of the newly-born occur through absorption from an umbilical 
sore, may it not also from a sore located elsewhere ? Decomposing and 
disintegrating animal tissue, wherever located, may be the source of septic 
infection. Moreover, medical literature contains histories of epidemics of 
puerperal fever in which newly-born infants perished with what was often 
designated erysipelas, but which the modern pathologist would unquestionably 
designate sepsis. The disease which I have described as umbilical phlegmon, 
a local sepsis, was commonly regarded by the older writers as a form of ery- 
sipelas. Dr. Condie, in his Treatise on Diseases of Children, described in the 
following lines what we would now designate sepsis : 

'' Erysipelas of infants very commonly occurs during the prevalence of 
epidemic puerperal fever. Children of mothers who become aff"ected with 
the fever are often born with erysipelatous inflammation : others are attacked 



144 DISEASES OF THE NEW-BORN. 

almost immediately after birth. Whether in these cases the disease is to be 
referred to a morbid matter applied to the skin in the womb, or to the same 
endemic or epidemic influence "which gives rise t6 the disease of the parent, 
it is difficult to say. According to M. Trousseau, infantile erysipelas is prin- 
cipally observed when puerperal fever prevails in the w^ards of the lying-in 
hospitals of Paris." 

The late Dr. Folsom of this city furnished me with the following sketch 
of cases which occurred in his practice and that of his partner. '-About 
the year 1840, being then in practice in New Bedford, Mass., I was called 
to visit a man who complained of pain in the knee. The next morning he 
was easier, but the following evening his symptoms grew worse, and, as I 
was engaged in a case of obstetrics, my partner. Dr. E. C, now dead, vis- 
ited him. At my call, next morning, I unexpectedly found the patient 
dying. The disease was obscure, and at the autopsy next day no lesion was 
discovered. In making the examination Dr. C. pricked his finger, and, expe- 
riencing little inconvenience from it at first, he attended a case of confinement 
on the following morning. A few hours subsequently he was taken sick, and 
I took charge of the lady, who died in three days, having the tumid abdomen 
and symptoms of childbed fever. The infant of the patient was seized when 
two days old with erysipelas appearing on the face and in spots on the trunk 
and limbs, and terminating fatally in one day. Dr. C.'s finger became swollen 
and painful, and the lymphatics of the forearm and arm became inflamed, 
presenting red lines, and the axillary glands suppurated. Though feverish 
and much prostrated, there was no appearance of erysipelas in his case. In 
about two weeks he resumed practice, and, as. at that time physicians in this 
country w^ere not fully aware of the danger of communicating puerperal fever, 
he attended two, three, or four obstetrical cases each week until the number 
reached fifteen. All the mothers died with symptoms of metro-peritonitis, 
and all the infants had erysipelas, commencing on the face or some part of 
the body, generally on the second or third day after birth, and in all termi- 
nating fatally within a week. This sad record was finally ended by the doc- 
tor's temporarily retiring from practice." 

What better description could be given of a malignant form of septic infec- 
tion ? It will be observed that the unfortunate doctor did not have erysipelas, 
but inflammation of the lymphatics, occurring from the poisoned finger, and 
the infant who first contracted the disease and died of one day's sickness 
exhibited red spots upon the trunk and limbs of an erysipelatous appear- 
ance. Did the doctor poison the mothers and infants at the same time by 
his digital examinations ? did he poison the mothers by his infected fingers, 
and they in turn poison the babies through the placental circulation ? or did 
the infected mothers communicate the poison through the breath or milk ? 
This is an interesting subject of inquiry in regard to which we are in the 
dark. Fortunately, the profession are now fully aware of the danger of sep- 
tic infection, so that no intelligent and prudent accoucheur would attend an 
obstetrical case after making a post-mortem examination or visiting a case 
of puerperal fever without change of clothing and thorough personal disin- 
fection, and consequently cases belonging to our third group are much more 
rare than formerly. 

It is evident that sepsis of the newly-born might be prevented in a large 
proportion of instances by proper antiseptic dressing of the navel. Boric 
acid is a feeble and inefficient antiseptic, and the borated cotton which was 
employed in dressing the navel when the cases in the maternity ward occurred 
which have been related above w^as inadequate to prevent infection. Of the 
powders which might be prescribed for this purpose, salicylic acid or deodor- 
ized iodoform mixed with starch would appear to be much more efficient. 



THRUSH. 145 

Crede's method of preventing purulent conjunctivitis by instilling one drop 
of a 2 per cent, solution of nitrate of silver between the lids has been very- 
effectual. Probably in a similar manner umbilical phlegmon might be pre- 
vented in maternity wards by bathing daily the umbilicus with a solution 
of the sublimate, grs. ij to the pint. 

When an umbilical phlegmon has commenced we have employed dusting 
with iodoform, the application to the navel every two hours of carbolized 
sweet oil (1 to 30), and bathing the navel with a solution of corrosive subli- 
mate, two grains to the pint of distilled or boiled water. In some of the 
cases thus treated when the phlegmons were small the patients gradually 
recovered, but in most of the cases the phlegmons were so large, and the 
microbes at such a distance from the umbilicus in the tissue of the abdomi- 
nal wall, that antiseptics applied upon and around the umbilicus were not 
curative. Newly-born infants are probably too young and feeble to be satis- 
factorily treated by incisions in the phlegmon and the application of anti- 
septics to the incised surfaces, else this treatment might be more efficient 
than treatment without such incisions. 

Thrush. 

The terms thrush, sprue, and muguet — the last from the French — are 
synonymous. They are used to designate a form of inflammation of the 
mucous surfaces the peculiar feature of which is the presence of points or 
patches of a curd-like appearance on the inflamed surface. The usual seat 
of thrush is the buccal membrane, but occasionally it occurs on the faucial 
and oesophageal surfaces. It is very rare in the subdiaphragmatic portion 
of the digestive tube, but a few such cases have been reported by Billard 
and others. It never occurs upon the membrane of the nostrils, larynx, or 
bronchial tubes, and it very seldom occurs upon any other surface without 
also being present upon the buccal mucous membrane. Thrush, then, is a 
stomatitis, pharyngitis, oesophagitis, or gastro-enteritis with the additional 
element which I have mentioned. 

Causes. — The younger the infant the greater is the liability to thrush 
when the causes favorable for its occurrence are present. It is therefore 
common in infants under the age of six weeks, and a majority of the cases 
occur under the age of six months. The common causes of this disease are 
such as ordinarily develop a stomatitis, prominent among which are improper 
feeding, indigestion, gastro-enteritis, and the cachectic state, whether arising 
from prematurity, congenital weakness, or enfeebling diseases. The most 
common and obvious of the causes alluded to is the use of indigestible and 
improper food, which produces a gastro-intestinal catarrh, soon followed by 
stomatitis. Thrush is therefore a common disease among foundlings in insti- 
tutions where these unfortunates are received, since they not only breathe 
an atmosphere which is often impure, but are deprived of the mother's milk, 
and are so frequently given a diet which is a poor substitute for it. Infants 
in crowded tenement-houses of the cities and in destitute families, whose 
diet is often very unsuitable, are much more liable to thrush than infants 
well fed and well cared for in well-to-do families. 

In infants under the age of three months the cause of thrush is often 
mild, and soon removed by better hygienic conditions and improvement in 
the diet. An improper diet for a few days, or a slight gastro-intestinal catarrh 
which quickly subsides when the cause ceases, is sufficient to develop the 
disease. In the newly-born the frequent use of sweetened carminatives or 
of sweetened dietetic mixtures administered by the nurse often gives rise to 
sprue, which ceases when these drinks are withheld and a proper mouth-wash 

10 



146 DISEASES OF THE NEW-BORN. 

applied. But after the age of six months, and especially after the age of 
one year, the condition giving rise to sprue is much more serious. After the 
age of twelve months sprue is comparatively rare, and when it does occur it 
is usually in the later stages of a protracted and exhausting disease ; and in 
such cases it is an unfavorable prognostic sign. Under such circumstances 
it occurs even in childhood, youth, and adult life, and is justly regarded as a 
complication of grave import. Thrush, being a parasitic disease, is com- 
municable by contact, like the parasite skin diseases. Thus in the wards of 
a foundling asylum the tip of a nursing-bottle used by different foundlings, 
if not properly cleaned after its use, may be the means of communicating it. 
Thrush is so common in young infants when the buccal surface is in a state 
favorable for its occurrence that it is probable that the specific germ may 
also be received from the atmosphere. 

Anatomical Characters. — The first stage of thrush is that of simple 
inflammation of the mucous surface. The mixed salivary and mucous secre- 
tions in the mouth, which are normally alkaline, become acid. There next 
appear upon the mucous surface minute semi-transparent points or granules, 
which, increasing, soon become white and opaque. Some of them remain as 
points, while others, extending and perhaps coalescing with those adjoining, 
form patches of greater or less extent. The white points or patches are 
unequally elevated. Their central part, which was first formed, is most 
raised, while their circumference projects but little above the epithelium. 
Their highest elevation is ordinarily not more than a line above the surface. 
They resemble closely in color and consistence portions of curdled milk, and 
the nurse often mistakes them for such and neglects to call attention to the 
state of the mouth. They are readily detached by a little force, when the 
mucous membrane underneath is seen to be in its integrity. Their color in 
the first days of sprue is white, and sometimes this color continues. In other 
cases they assume, if the disease be protracted, a yellowish hue. 

Their true nature, long unknown, was finally revealed by microscopy. 
They consist in part of epithelial cells and in part of a vegetable growth. 
This parasite is the O'idmm albicans, discovered by Berg of Stockholm, but 
more fully described by Gruby and Charles Robin. The roots of the parasite 
are transparent, and they penetrate the epithelial layer sometimes even to 
the basement membrane. The branches arising from these rootlets divide 
and subdivide at an acute angle, and under the microscope are seen to con- 
sist of elongated cells with one or two nuclei. The branches or the mycelium 
is formed by the union of the cells at their extremities. Numerous spherical 
or ovoid spores are also present surrounding the mycelium and covering the 
epithelial cells. Haller states that he has identified this parasite with the 
O'idmm lactis, which occurs in milk undergoing acid fermentation. The 
spores are primarily developed, and are found in the scraping of the mucous 
surface in the vicinity of the patches of sprue. In two instances in examin- 
ing the product of thrush removed from the oesophagus I found that the 
parasitic plant was the PenicilUum glancum or a conferva closely resem- 
bling it. 

We have described the ordinary form of thrush as it occurs in young 
children, but if the patches are of large size and abundant, and the buccal 
surface generally of a deep-red color, there is usually some severe prostrating 
and dangerous disease on which the thrush has supervened. We have already 
alluded to the fact that thrush in its severe forms often results from and com- 
plicates some grave disease, as protracted gastro-intestinal catarrh or a chronic 
pulmonary malady. Hence some writers who have observed thrush in found- 
ling asylums regard it as one of the most serious maladies of early life. Val- 
leix, in a book of more than seven hundred pages relating to the diseases of 



THRUSH. 



147 



children, devotes more than one-third of it to Fig. 8. 

the consideration of muguet, but those patho- 
logical conditions pertaining to the digestive ap- 
paratus which most observers regard as distinct 
from sprue, though sustaining a causal relation 
to it, he includes in the description of muguet. 
Of 2-4: cases the records of which he publishes, 
22 died, but their death was in most instances 
due to gastro-intestinal inflammation, which 
the author describes under the term ''muguet.' 
Most writers properly restrict, as stated above, 
the term thrush, sprue, or muguet to those 
inflammations of mucous surfaces which are 
accompanied by the peculiar parasitic out- 
growth, regarding the severe subdiaphragmatic 
inflammations from which Yalleix's patients 
died as distinct from muguet, though sus- 
taining a causal relation to it. In the post- 
mortem examinations which I have witnessed 
in the Nursery and Child's Hospital, Infant 
Asylum, and Foundling Asylum of this city, 
of those having thrush at the time of death, 
who for the most part have been infants un- 
der the age of three months, I have frequently 
found evidences of inflammation in every di- 
vision of the alimentary canal. The parasitic 
growth was, however, never seen below the 
oesophagus. Parrot, however, states that he 
has discovered it in rare instances in the 
larynx, stomach, and intestines. 

Sy3IPT0MS. — Thrush in itself does not give 
rise to any symptoms except those that pertain to the surface which is the seat 
of the parasitic growth. Other symptoms are not referable to it, but to the 
diseases in the course of which it is developed and which it complicates. Sprue 




Pavement epithelium covered by 
spores of the O'idium albicans (Ch. 
Robin). 







Spores and Branches of the O'idium albicans (Ch. Robin). 



148 DISEASES OF THE NEW-BORN. 

is preceded and accompanied by the symptoms of gastro-intestinal catarrh or 
some other disease which aifects the digestive apparatus, and causes acidity of 
the buccal surface. The mucous membrane, upon which the cryptogam is 
soon to appear, becomes red, hot, tender to the touch. As we have stated above, 
it gives the acid reaction more or less marked to litmus-paper, and in the 
scraping from its surface placed under the microscope the spherical or oval 
spores of the O'idhim cdbicans are observed. A few hours later small white 
points appear, at first scarcely visible, produced by the cryptogamic growth 
and the epithelial and amorphous matter adherent to it. 

These points enlarge, and within a day or two present the well-known 
appearance of small masses or patches of curdled milk. They are fragile 
and readily detached, but are soon replaced by others so long as the cause 
continues. In the worst forms of thrush the surface upon which the cryp- 
togam appears not only presents the ordinary features of severe inflammation, 
such as heat, redness, and tenderness, but it is sometimes deficient in the 
natural secretion, so as to present a dry or parched appearance. In these 
severe cases there is usually in young infants obstinate and protracted 
inflammation of subdiaphragmatic portions of the digestive tube. The 24 
cases related by A^alleix, alluded to above, 22 of which were fatal, were of 
this kind. But the gravity of such cases, in which thirst, anorexia, restless- 
ness, vomiting, diarrhoea, and progressive emaciation occur, is due, as stated 
above, to the primary disease which has produced the conditions favorable 
for the occurrence of sprue. If sprue occur, its symptoms should be dif- 
ferentiated from the more pronounced symptoms of the disease which it com- 
plicates. 

Diagnosis. — This is not difficult, so far as relates to thrush of the buccal 
surface, for simple inspection reveals its presence. If a particle of one of 
the patches be placed under the microscope, the mycelium and spores of the 
O'idium albicans are readily detected. Only the inexperienced could mistake 
the diphtheritic exudate for the growth of sprue or vice versa. The diph- 
theritic pellicle penetrates the mucous membrane, from which it is detached 
with difficulty, leaving underneath a raw^ and bleeding surface, and it is 
thick and tough, contrasting in these particulars with the product of sprue. 
Enlargement of the cervical glands is also common in diphtheria and is absent 
in sprue. 

Particles of coagulated casein upon the tongue and gums bear a close 
resemblance to the patches of thrush, but their relation to the mucous mem- 
brane is simply that of contact, and they are removed by a spoonful of 
water. 

Prognosis. — The duration of thrush varies according to the duration and 
nature of the primary disease which it complicates. In young infants who 
have indigestion or slight gastro-intestinal catarrh it is quickly cured by 
appropriate local treatment if the nutriment given be of the proper kind and 
the stomach and intestines be restored to their normal state. On the other 
hand, thrush occurring in the course of chronic and highly debilitating dis- 
eases is not so quickly cured, or if cured is likely to return. It does not 
materially increase the gravity of the malady in the course of which it 
occurs, but when it complicates a chronic disease it indicates a reduced state 
of the system, an impairment of the general nutrition, which if it continue 
is likely to end fatally. As M. Bouchut has pointed out, when Baron states 
that 109 out of 140 patients with muguet died of this disease, and Valleix, 
as I have stated above, says that he lost 22 out of 24 cases from the same 
cause, they attribute to a comparatively unimportant complication what was 
really due to a grave internal disease. Thrush does not itself cause death, 
though it may be a sign of bad omen. Death when it occurs is from a vis- 



THRUSH. 149 

ceral aifection which precedes and accompanies the sprue, and is likely to 
continue after every vestige of the latter is removed by local measures, unless 
it receive appropriate internal treatment. 

Sprue is a bad omen if the tongue and buccal surface be dry, hot, and 
highly injected, the coating of the tongue of brownish color, the infant fret- 
ful with the appearance of suffering in its physiognomy, and having progres- 
sive loss of flesh and strength. Such symptoms indicate in most instances a 
fatal form of gastro-intestinal catarrh. On the other hand, in young infants, 
since indigestion and slight gastro-intestinal derangements are adequate to 
cause an acid state of the buccal surface and the development and extension 
of the Oidivm albicans^ the large majority of the cases of thrush in which the 
general condition is good and the stomatitis mild are quickly cured by appro- 
priate treatment. 

Treatment. — Since the common cause of thrush in infancy is the use of 
indigestible or improper food, the physician should ascertain the nature and 
mode of preparation of the infant's diet, and, if it be faulty, should direct 
one that is better. If the infant be bottle-fed, the mother's milk or that 
of a wet-nurse should, if practicable, be substituted for the artificial feed- 
ing ; but if this be impossible, a diet should be selected which bears the 
closest possible resemblance to the mother's milk in digestibility and nutri- 
tive properties. 

There is often in thrush an excess of acidity in the digestive tube, and 
an alkali is required. Trousseau recommends the addition of saccharate of 
lime to the milk. Children with this disease should also be taken from filthy 
and damp apartments to those in which the air is pure and dry. and their 
mouths and persons should be kept clean. 

The remedy in common use in the treatment of thrush, and which is 
usually effectual, is borax. This, if applied sufficiently often to the aff"ected 
membrane, not only destroys the parasitic growth, but prevents its reproduc- 
tion. It is commonly employed with honey or in a powder with sugar or 
dissolved in water. The officinal mel boracis. consisting of one part of borax 
to eight of honey, is so much used in families that it may be considered 
almost a domestic remedy. There is. however, an objection to using any 
application for the removal of thrush which contains either sugar or honey, 
since either substance remaining in the mouth would rather promote the 
growth of the parasite. Still, it is desirable to employ a wash of such con- 
sistence that it will remain a longer time in contact with the buccal surface 
than will a simple solution in water. I know no better vehicle for the borax 
than glycerin, which has the advantage of consistence, does not undergo any 
chemical change, and has no unpleasant flavor. The borax may be used dis- 
solved in glycerin, with or without some flavoring ingredient : 

R. Sodii borat., ^j ; 

Glycerinse, ^ij ; 

Aquae, gvj. Misce. 

Borax should be used four or five times daily, and continued for a time after 
the disease has disappeared from sight, since the roots of the plant must be 
destroyed or the branches are rapidly reproduced. It should be applied by a 
camel's-hair pencil or with a soft cloth upon the finger or a stick. It should 
be so freely used in extensive and severe forms of the disease that the infant 
will swallow some, since the entire oesophagus is often also the seat of sprue 
in such cases. In the intervals between the applications of borax, if the 
buccal surface be hot, dry, and tender, so as to increase the fretfulness of the 
infant, it is well to use mucilaginous washes, as the mucilage of acacia or 



150 H^MATEMESIS AND HELENA NEONATORUM. 

mallows. If the disease continue notwithstanding the use of these measures, 
the mouth should be occasionally washed with a weak solution of nitrate of 
silver or sulphate of zinc : 

R. Zinci sulph., gr. ij-iv; 

Aq. rosse, ^ij. Misce. 

In many cases, however, the treatment of thrush is of less importance 
than that of the disease which the thrush complicates. The remedial meas- 
ures which I have mentioned then become subordinate to those employed for 
the graver disease. When this disease is relieved and the general health 
improves, thrush is more easily and permanently cured than during the state 
of feebleness and ill-health. 



CHAPTER IV. 

HiEMATEMESIS AND MEL^NA NEONATORUM. 

Hemorrhage from the gastro-intestinal surface occurs in children from 
various causes. It is a common symptom of intussusception in infants. It 
occurs from dysentery and purpura and from the syphilitic dyscrasia. It 
has been observed in polypus of the rectum and in anal fissures. In rare 
instances it occurs from the irritation of lumbrici, from foreign substances 
which have been swallowed, and from the ulceration of typhoid fever. Intes- 
tinal hemorrhage from such causes is a symptom of constitutional or local dis- 
ease. But in newly-born infants it sometimes occurs without other symptoms 
or without other appreciable disease, and therefore is regarded as an essential 
malady. 

Melasna neonatorum was mentioned by Storck in 1750, and various wri- 
ters at different times alluded to it or briefly described it prior to 1825. In 
1825 it was more fully treated of by Hesse than by any of his predecessors.^ 
The monograph published by him was valuable, as it contained his own obser- 
vations and those of contemporary physicians communicated to him, as well 
as the investigations of his predecessors. Dr. Rahn-Escher of Zurich (1835), 
Meisner (1838), Kiwisch (1841), Rumpe (1841), Hoffman (1842), and Helm- 
brecht (1843) published memoirs or related cases of melasna. Several of the 
best-known authors on diseases of children, long recognized as authorities in 
this branch of practice, have also written on intestinal hemorrhage, as Billard, 
Vogel, Rilliet and Barthez, Barrier, Bouchut, West, Eustace Smith, and Good- 
hart, so that the literature of this disease is no longer meagre. 

Age. — In the statistics of Billard, embracing 15 cases, 8 were between 
the ages of one and six days, 4 between the ages of six and eight days, and 
3 between the ages of ten and eighteen days. Of 20 cases embraced in the 
memoir of Rilliet and Barthez, 9 were at or under the age of thirty-six 
hours when the hemorrhage began, 5 between the ages of two and four days, 
2 between six and eleven days, and 2 at the ages of fifteen and twenty 
weeks. Of 50 cases collated by Groom ^ from various sources, gastro-intes- 
tinal hemorrhage took place in 30 between the first and sixth days, in 8 
between the sixth and eighth days, in 4 between the eighth and twelfth days, 
and in 8 between the twelfth and eighteenth days. The bleeding began in 

1 Annalen von Pierer, 1825, Heft 6. ^ Medical Times and Gaz., Oct., 1880. 



ETIOLOGY. 151 

6 within the first twenty-four hours. These statistics, which correspond with 
those of other observers, show that in a large majority of cases the hemor- 
rhage occurs within the first twenty-four hours. Hsematemesis also takes 
place along with the intestinal hemorrhage in a considerable proportion of 
cases. 

Etiology. — The cause of melsena of the newly-born is involved in some 
obscurity. To a considerable extent the causes are the same as in hemor- 
rhage from the umbilicus, which we have treated of in a foregoing page. A 
predisposition to this and other forms of hemorrhage is sometimes inherited. 
Dr. Rahn-Escher states that the mothers sometimes have digestive ailments 
or other forms of ill-health, which he thinks produce atony of the vessels in 
the infants. The infant sometimes belongs to a family of bleeders and inher- 
its haemophilia. In the Medical Times and Gazette for October, 1880, Dr. 
Croom relates 4 cases in which there appeared to be an hereditary tendency 
to bleeding. In 1 of the cases the father was subject to hemorrhages ; in 
another the pressure of the forceps produced extensive ecchymoses on both 
sides of the head. We have stated in our remarks on umbilical hemorrhage 
that newly-born infants affected by syphilis are very liable to intestinal 
and other forms of hemorrhage from the dyscrasia present or from anatomi- 
cal changes in the walls of the minute vessels, or, as is probable, from both 
causes. Our article on umbilical hemorrhage contains the statistics of 
Mracek, who at the autopsies of 160 syphilitic infants observed internal 
hemorrhages in 42, but in only 4 of these was extravasated blood present in 
the intestines. 

But the majority of the neonati who have gastro-intestinal hemorrhage 
do not appear to have any inherited dyscrasia or taint of system. Certainly 
the instances are exceptional in which the infants belong to families of 
" bleeders" or have the syphilitic dyscrasia. We must look for other causes 
apart from these. Billard attributes melsena of the newly-born to conges- 
tion of the vessels. Says he: "I have examined 15 cases of passive intes- 
tinal hemorrhage Most of them were remarkable for the plethoric 

condition of their bodies and the general congestion of their integuments. 
.... In all the large abdominal vessels, the liver, spleen, lungs, and heart 
were considerably engorged with blood." He adds: "It cannot be too 
strongly recommended to accoucheurs to allow the umbilical cord to bleed 
when a child is observed to be in a state of asphyxia ; for it has already 
been seen what serious effects follow from a superabundance of blood in 
young infants."^ Vogel says: "The turgescence of the mesenteric arteries 
and their systems of capillaries, seen even in the physiological state, and 
produced by the sudden closure of the umbilical arteries, so important in 
the foetus, and which arise directly from the hypogastric arteries, may be 
looked upon as a cause of this disease. An especial thinness of the walls or 
friability of the afi"ected system of vessels must certainly play a part here, 
because otherwise this, in reality, very rare form of hemorrhage would have 
to occur much niore frequently. The closure of the ductus venosus Arantii, 
and especially that of the branch of the umbilical vein opening into the 
portal vein, deserves more frequent and stricter investigation to explain this 
hemorrhage." 

Rilliet and Barthez attach but little importance to the causes of melaena 
assigned by writers who preceded them, but state that it is easy to conceive 
that hypergemia of the intestinal tube, which is normal in the newly-born, 
might be increased by atony of the vessels or impeded abdominal circulation, 
through arrest of the circulation in the portal vein, so that hemorrhage 
would be likely to occur. Incomplete establishment of respiration, in which 
^ Treatise on the Diseases of Infants. 



152 hjEmatemesis and melmna neonatorum. 

congestion of organs occurs, and especially of the intestines, they regard as 
a predisposing cause. They admit hereditary influence in certain cases, as 
when a parent has been subject to hemorrhage. M. Bouchut^ makes three 
groups of cases of melaena, according to the supposed etiology, as follows : 
First, melaena from purpura ; second, from passive congestion, the result of 
compression at birth ; third, from acute or chronic inflammation of the gas- 
tro-intestinal surface. Dr. West believes that tedious and difficult labor, in 
which the head of the child is compressed and abdomen injured, is an occa- 
sional cause of intestinal hemorrhage. The tardy and difficult establishment 
of respiration he also thinks may be a predisposing cause, but he adds, " Very 
often no reason can be assigned for it." In two post-mortem examinations 
which he made no adequate cause was discovered. Braun ^ mentions among 
the probable causes congestion of mesenteric vessels, pressure during birth, 
heredity, intra-uterine malnutrition. Steiner^ believes that intestinal hemor- 
rhage occurs sometimes from a round perforating ulcer due to fatty degene- 
ration of the arteries. Hecker, Buhl, Spiegelberg, and Leopold Landau 
relate cases, six in all, in which abscesses or ulcers were observed in the 
stomach or duodenum, or in both. Landau expresses the opinion that these 
lesions occurring in the gastro-duodenal surface are produced by small embo- 
lisms. Beinhold* relates the case of an infant born May 15th who had 
haematemesis and melsena on the first day, and died May ITth. There was 
apparently epigastric tenderness. All the organs were anaemic, and the 
stomach contained seven or eight ulcers with edges slightly raised. No 
emboli could be discovered, but the umbilical vein contained a brownish-red 
clot. 

On the other hand, J. Halliday Croom, lecturer on midwifery and dis- 
eases of women at the School of Medicine, Edinburgh, made the autopsy 
of a child that died of melaena at the age of half a day. The gastro-intes- 
tinal surface was carefully examined, and no abscess, ulcer, or erosion was 
discovered, but some congestion was observed in the lower part of the intes- 
tine. He alludes to another case, described by Helmbrecht, in which the only 
apparent morbid condition was congestion of the rectum. In another case, 
observed by Dr. Croom, an infant of three weeks, previously well, died of 
hsematemesis and melsena. Both auricles contained firm clots, and in the 
aorta was a clot partly decolorized. The only abnormal appearance in the 
digestive tract was capillary injection of the duodenal surface.^ 

Epstein of Prague® in an interesting monograph on melaena neonatorum 
states that hemorrhage occurs in the newly-born from various causes — from 
disturbance of the circulation leading to congestion, from disease of the ves- 
sels, and from disease of the blood itself. In infants born partly asphyxiated 
after tedious labor, or in weakly infants with atelectasis, Epstein says that 
hypersemia, hemorrhagic erosions, ulcerations, and actual hemorrhage of the 
gastro-intestinal surface are likely to occur. He believes that the most com- 
mon cause of melaena is temporary congestion of the finer capillary vessels. 
When the surface of the stomach has been sprinkled with ecchymoses, small 
gastric ulcers have been present, caused by emboli in the gastro-duodenal 
vessels, resulting from thrombi in the umbilical vein. 

From the above quite numerous observations we are able to affirm that 
hemorrhage from the stomach and intestines in the newly-born occurs from 
diff'erent causes, prominent among which are — 1st, haemophilia ; 2d, inherited 
syphilis ; 3d, congestion of the gastro-intestinal surface ; 4th, ulcers occurring 

^ Traiie 'pratique des Maladies des Nouveaux-nes. 

^ Compendium des Kiiiderheilkunde, Vienna, 1871. 

•^ Diseases of Children. * Deutsche med. Woch. No. 28, 1881. 

^ Med. Times and Gaz., Oct., 1880. « Allcjem. Wien. Med. Zeit., No. 49, 1882. 



BIARRHCEA OF THE NEWLY-BORN. 153 

especially in the stomach, whether produced by emboli resulting from throm- 
bosis in the umbilical vein or from other causes. 

Diagnosis ; Prognosis. — If the infant vomit blood, the nipple of the 
mother or wet-nurse should be inspected, for a considerable amount of blood 
is sometimes drawn by suction from the nipple. If no abrasion or sore be 
discovered upon or around the nipple or upon the lips or in the mouth of the 
infant, we may assume that hemorrhage is occurring from the stomach or 
upper part of the intestines of the infant. The presence of blood upon the 
diaper without any fissure upon the anus or external source of its occurrence 
is evidence of intestinal hemorrhage. The blood is dark and more or less 
changed by digestion or the action of the intestinal secretions if it have lain 
some time in tlie intestines. The pallor of the infant and increasing feeble- 
ness are evidence of the loss of blood. But in one instance myself and two 
other physicians were deceived by a midwife who had loosely ligated the 
umbilical cord, so that fatal hemorrhage occurred from it. The case was 
reported as one of intestinal hemorrhage, and was recorded as such in the 
statistics of the Health Board. The source of the hemorrhage was ascer- 
tained by a post-mortem examination which we were fortunate in obtaining. 
The gastro-intestinal surface was normal except its extreme bloodlessness 
and pallor. 

The PROGNOSIS is in most instances unfavorable, but if the infant be 
strong and the amount of hemorrhage small, we may hold out some encour- 
agement of a favorable result. It is possible, indeed, that a considerable 
amount of blood be lost and the infant recover. But weakly infants who 
have an abundant hemorrhage sink rapidly. If the bleeding do not cease in 
twenty-four hours, death will probably be the result. 

Treatment. — The child should be nourished at the breast if possible, 
and a little ice-water be given with a spoon along with the breast-milk. If 
the infant do not have breast-milk, peptonized milk may be employed. The 
food, of whatever kind, should be given cool. It has been recommended to 
apply the ice-bag over the abdomen while warm applications are made to the 
extremities. One grain of tannic or gallic acid dissolved in cool water may 
be given every hour, or one or two drops of turpentine. If the child exhibit 
signs of failing strength, a few drops of brandy should be given at short 
intervals in cold peptonized milk. 

DiARRHCEA OF THE NeWLY-BORN. 

The colostrum, or the first secretion of the mammary glands after parturi- 
tion, contains more oily matter and sugar than occur in the subsequent secre- 
tion. In consequence of this peculiarity in its composition the colostrum 
has a laxative effect by which the meconium is expelled. If the mammary 
glands continue to secrete colostrum after the first week, diarrhoea is likely 
to result. A more common cause of diarrhoea of the newly-born is the 
employment of various sweetened mixtures by mothers or nurses in the 
belief that the breast-milk is inadequate, or they are employed for the pur- 
pose of relieving the supposed colicky pains whenever the baby frets. Cane- 
sugar added to the various mint teas not only gives rise to diarrhoea, but also 
in time to more or less gastro-intestinal catarrh and stomatitis, with the occur- 
rence of sprue. Sprue is more common in the newly-born than at any other 
period of life, and it can usually, according to my experience, be traced to 
the use of improper sweetened mixtures. The infant immediately after birth 
may be given a little sweetened water or a teaspoonful of sweet oil to aid in 
the expulsion of the meconium, but subsequently, in the great majority of 
cases, no carminative or nutritive mixtures are required. The breasts of the 



164 H^MATEMESIS AND MEL^NA NEONATORUM. 

mother if she have the usual health furnish all that is needed. The neonatus 
requires almost no nutriment during the first three days, and the breasts fur- 
nish but little during this time, but frequent traction upon the nipple pro- 
motes the mammary secretion, and after the third day, in ordinary cases, 
sufficient nutriment is obtained from the breasts to supply the wants of the 
system and promote a healthy growth. If what is natural were left to itself, 
and no artificial measures were employed, the result in most instances would 
be good; but the unfortunate practice of filling the infant's stomach with 
various admixtures disturbs normal digestion, impairs the appetite, causes 
colicky pains, vomiting, and diarrhoea, and, if persisted in, gastro-intestinal 
catarrh. In many cases green fermenting and unhealthy stools cease, and 
a more normal state of the digestive apparatus is produced by forbid- 
ding the use of superfluous and injurious food and drinks which had been 
given to supplement wet-nursing in the mistaken belief that more food was 
required. Food in excess, even if it be of the proper quality, even if it be 
breast-milk, usually causes diarrhoea if it be not vomited, since, not being 
digested, it undergoes fermentative changes, and acts as an irritant until it is 
expelled. Food containing a large proportion of sugar is laxative in con- 
sequence of the sugar. 

Diarrhoea in the newly-born, whatever its cause, should be immediately 
arrested. After the meconium is removed by the action of the colostrum, 
three daily evacuations from the bowels are sufficient. A larger number is 
usually attended with loss of flesh and strength. The use of sweetened 
mixtures, which nurses are in the habit of administering when infants are 
not well, as catnip, fennel, or aniseed tea, we repeat, must be strictly for- 
bidden. A mother with a sick and fretful infant usually applies it to the 
breast too frequently, even every half hour during the day. This should 
also be strictly forbidden. The infant, like the adult, should take food at 
stated intervals, so that the digestive organs may have some respite from the 
task of digestion. The application of the new-born infant to the breast twelve 
times in twenty-four hours is sufficient for its nutrition, and the mother's health 
is better preserved and her milk of better quality than when she is deprived of 
the needed rest by more frequent suckling. If the infant be unfortunately 
deprived of breast-milk and be bottle-fed, the utmost care is required in the 
selection and preparation of the food, as well as in determining the amount 
of food to be given and the frequency of feeding. Facts relating to this 
important subject have been presented in preceding pages. Young bottle- 
fed infants with too frequent and unhealthy stools sometimes do well with 
peptonized milk, especially if flour prepared by long boiling be added to it. 
The important advantage possessed by this flour is that its starch is con- 
verted into the soluble form, and a considerable part of it into dextrin, 
so that it can apparently be digested by young infants more readily than 
ordinary flour. A teaspoonful of the flour long boiled may be added to 
twenty teaspoonfuls of peptonized milk for young infants with diarrhoea. 
The beneficial eff"ect of the flour is due largely to its mechanical action in 
separating the particles of casein, so that they can be acted on more readily 
by the gastric juice, which in young infants is secreted in small quantity. 
Sometimes in treating the diarrhoea of young infants, if it be severe, it is 
better to withhold entirely milk in any form a few days, and give in its place 
a light gruel prepared by adding the barley or wheat flour, long boiled, to water 
in the proportion of one part to twenty. When it is heated to the boiling- 
point to destroy any microbes in the water, place it upon ice or in cool water, 
and when its temperature is reduced below blood-heat the white of an egg or 
half an egg may be added with sufficient salt. This farinaceous diet some- 
times aids materially in checking the diarrhoea. Dextrin can be digested by 



COXSTIPATION OF THE XEWLY-BOBN. 155 

the youngest infant, and the little patient may be sufficiently nourished for a 
week or more by the wheat or barley flour prepared in the manner stated 
in the chapter on infant feeding, with the salt and perhaps white of egg- 
added. 

If the diarrhoea do not cease by the use of the proper diet giyen in suit- 
able quantity at proper intervals, which should not be oftener than two and 
a half to three hours, medicinal treatment is needed. I have found the fol- 
lowing prescriptions very useful for the diarrhoea of infants under the age of 
one month, as well as for those that are older : 

R. Bismutbi subnitrat., ^iij ; 

Pepsini pari in lamellis, ^j. Misce. 

Grive as much as goes on a ten-cent piece before each feeding. 

R. Bismuthi subnitrat., ,^ij ; 

Misturte cret», ^ij. Misce. 

Shake bottle, and give twenty drops midway between the feedings to a child 
of two weeks. This alkaline mixture neutralizes the lactic, butyric, or other 
injurious acid which may exist in excess in the stomach or intestines. In 
some instances one or two drops of paregoric, given three or four times daily, 
have a salutary effect by diminishing the peristalsis. 

Constipation of the Newly-born. 

In the infant constipation results from several different causes. The most 
serious and obstinate form of it, to which the term obstipation is more appro- 
priately applied, arises from intestinal malformations. In rare instances con- 
genital obstruction occurs in the small intestines. It is sometimes produced 
by cystic tumors or twisting of the intestine. Congenital stenosis occasion- 
ally occurs at the ileo-csecal orifice. Thus, in the Transactions of the London 
Fatholoyical Societij for 1870 is the history of a case in which there was such 
narrowing of the ileo-csecal orifice, believed to be congenital, that a No. 9 
catheter could barely be passed through it. The patient lived until his 
thirty-second year, but throughout his life suffered from constipation and 
colic. After his death the ileum next to the ileo-cfecal valve was found to 
have a diameter of seven inches, while the large intestine was much atro- 
phied and its entire lumen contracted from disuse. Occasionally the stenosis 
occurs a little above the ileo-caecal orifice, and rarely in the duodenum at the 
point of union of the pancreatic or bile-duct with the intestine. The obstacle 
in some instances appears to be hypertrophied valvulaa conniventes. the edges 
of two opposite folds being more or less adherent. Such congenital intestinal 
obstructions — whether, as is probable, produced by inflammations in the foetus 
or from simple j^erverted nutrition ; whether arising from the syphilitic ca- 
chexia or other cause — of course retard the evacuations according to their loca- 
tion and the amount of closure. The same degree of stenosis in the colon or 
rectum obviously causes a more constipatins: effect than in the small intes- 
tines, since the latter have more mobility than the former and their contents 
are more liquid. 

But the most common of the congenital obstructions in the intestines 
occur from malformations of the rectum. These malformations vary con- 
siderably in different cases. They may be classified in at least foiir different 
groups : 1st. The anus may appear normal, but instead of the normal rectum 
two cul-de-sacs are present, representing the upper and lower ends of the rec- 



156 HJEMATEMESIS AND MEL.ENA NEONATORUM. 

turn, and connected by an occluded segment of the rectum or by a firm fibrous 
cord. 2d. The anus is absent, and the rectum has a fistulous opening in the 
perineum, or through the scrotum in the male or vulva in the female. In 
the embryonic development the outlet of the rectum was formed too near 
and encroached upon the sexual apparatus. 3d. The anus is absent, and 
there is no external fistulous opening representing the anus, but the rectum 
opens at some point upon the mucous membrane of. the genito-urinary appa- 
ratus. 4th. Anus absent and the entire lower part of the rectum obliterated. 
The upper portion of the rectum terminates in a cul-de-sac in the neighbor- 
hood of the promontory. Some of these malformations do not prevent the 
discharge of fecal matter, but when there is closure of the rectum and no 
fistulous opening, of course no evacuation of the intestines can occur unless 
relief be obtained by surgical measures. In the ordinary form of occlusion 
a portion of the rectum is represented by a cord, or a firm, unyielding septum 
shuts off the lower part of the rectum from that above, so that defecation is 
impossible. The infant with this serious malformation takes the breast for a 
time like other infants, but the intestines soon become distended with fecal 
matter, and restlessness from the distension and vomiting occur. The 
only mode of relief is by an incision or puncture through tbe obstruction ; 
but a large proportion of infants with this obstructive malformation die 
whether operated on or not. The incision or puncture should be made as 
soon as the obstruction is discovered, and if successful in reaching the dis- 
tended intestine above the malformation, the passage thus made should be 
kept open by tubing of the proper size if the infant live. If the operation 
be unsuccessful in releasing the imprisoned fecal matter, an artificial anus 
may be made on the left or right side. 

The great length of the sigmoid flexure in infancy, and the curvatures 
which occur in consequence, more in number than in older children, tend to 
retard the descent of fecal matter and promote constipation. In the adult 
numerous depressions and inequalities in the colon retard the downward move- 
ment of the intestinal contents, but in infancy the surface of the colon is com- 
paratively smooth and even, and the detention, so far as any exists, occurs from 
the curvatures or loops, which are sometimes twisted partially on their axes. 
The sigmoid flexure is so long in infants under the age of ten, and especially of 
six months, that the curvatures usually lie in part to the right of the median 
line, and even in the right iliac fossa. Those who have witnessed the post- 
mortem examinations of young infants in the asylums find no difficulty in 
accepting the statement of certain writers that the curvatures or loops in the 
sigmoid flexure, which sometimes extend as high as the umbilicus, and later- 
ally to the right iliac fossa, cause habitual constipation in some infants. 

Occasionally in young infants, as well as in those who are older, the 
intestines act sluggishly from insufficiency of food. Thus the infant some- 
times hangs an unusually longtime on the breast, and the mother or wet- 
nurse believes it to be a hearty nurser, when there is really a deficiency of 
milk, and the stools are scanty and infrequent from lack of material : under 
such circumstances the infant is restless when away from the breast, or, not 
being fed, loses flesh, and soon has the appearance of one in ill-health. These 
symptoms disappear by a more liberal allowance of food of proper quality. 
Thus, recently a young infant was brought to me suffering from constipation 
and fretfulness, with progressive loss of flesh and strength and with abundant 
urination. Its only food, prepared through the advice of a physician, con- 
sisted of a teaspoonful of condensed milk to one pint of water. By a more 
liberal supply of food the constipation disappeared. 

Again, a constipated state of the bowels occasionally occurs in infants 
who nurse heartily and seem to obtain a sufficient quantity of milk ; and the 



CONSTIPATION OF THE NEWLY-BORX. 157 

cause of it appears to be in the state of the digestive organs, and not in the 
milk. We find now and then that breast-milk has a constipating effect, 
although we discover nothing in the mother's diet or health to cause this 
result. The comparison of ordinary breast-milk with colostrum may furnish 
an explanation of the constipation under such circumstances. Colostrum is 
known to be more laxative than ordinary milk, and it differs from it chemi- 
cally in containing more butter, sugar, and salts. Hence the theory seems 
plausible that when breast-milk is constipating these elements occur in less 
than the normal quantity, and we will find that treatment suggested by this 
theory tends to obviate the constipation. 

Constipation has also been attributed to a deficiency in the intestinal 
secretions and to too great viscidity of them from lack of water. Deficient 
peristalsis, whether from congenital weakness or other cause, also leads to 
constipation. The use of starchy foods without sugar or with but little sugar 
also sometimes has a constipating effect. 

Gautier of Greneva, Switzerland, states that an anal fissure is a common 
cause of constipation, whether in the newly-born or older infants. If such a 
fissure be present, pain in defecation might instinctively lead the infant to 
resist the desire to evacuate the bowels and to postpone the act, so as to estab- 
lish a constipated habit ; but if such fissures are common in this country, 
except in the syphilitic, they have escaped our notice. 

Finally, constipation has a tendency to perpetuate itself, since retained 
feculent matter becomes more consistent and firmer, and the contractile power 
of the muscular tissue becomes weakened by over-distension. 

Symptoms. — When there is a mechanical cause of scanty and infrequent 
defecation, the acuteness of the symptoms and the suffering are usually pro- 
portionate to the degree of obstruction. In cases of complete obstruction of 
the intestines, as in imperforate rectum, fecal accumulation occurs above 
the obstruction. Under such circumstances distension of the abdomen, vom- 
iting, fretfulness apparently from the abdominal pain, and progressive loss of 
ffesh and strength, indicate the serious nature of the disease. 

In constipation from other causes — that is, without obstruction except 
such as arises from fecal accumulation — the condition of the infant may 
attract little attention at first ; but if it do not have proper evacuations it 
soon begins to suffer in its health. Fretfulness, an unhealthy physiognomy, vom- 
iting, and more or less fever occur, until the patient is relieved of the ailment. 

A beautiful and conservative provision in the system is that by which 
vicarious functions are established to relieve organs which imperfectly per- 
form their part. While the intestinal surface is to a great degree eliminative, 
so that noxious and effete products are expelled from the system in the stools, 
it possesses also in a high degree an absorbent function, as all who employ 
rectal alimentation are aware. If the intestine fail to perform its function 
of defecation, so that feculent matter collects within it and begins to exert 
pressure on the intestinal surface, more or less of the liquid portion is taken 
up by the absorbents, and, entering the general circulation, it finds a mode 
of escape through other emunctories. The general ill-health or languor, the 
furred tongue, foul breath, and pain in the head which characterize these 
cases are no doubt due to the absorption into the blood of noxious products 
derived from retained feculent matter. But cases to which this description 
is applicable are not common in early infancy. In the infant the retention 
is often only in the rectum or rectum and sigmoid flexure, and the symptoms 
are mild and are relieved by free evacuations, which are easily obtained. 
Between these mild cases and the graver forms of constipation, such as result 
from mechanical obstructions, there is every intermediate grade, attended by 
symptoms proportionately severe. 



158 HJEMATEMESIS AND MEL JENA NEONATORUM. 

Treatment. — It is very important that constipation in the infant should 
be detected and promptly treated. Not only its present health, but future 
well-being, requires this, for the longer the constipated habit continues the 
more difficult is the cure ; and an examination of the records of extreme 
constipation in adult life which are found in medical literature reveals the 
fact that in many instances the sluggish state of the intestines commenced 
in early infancy. The following case, observed by Renauldin and related by 
Dr. Copland in his Medical Dictionary^ may be given as an example : A med- 
ical officer in the French service had been constipated from birth. He ate 
like others, but habitually had only one stool in a month or two months, and 
at the age of forty-two three to four months elapsed between the evacuations. 
His abdomen was greatly distended and painful, and he seldom passed' more 
than four to six stools in the year ; but he lived until the age of fifty-four 
years. After his death the constipation was found to be due to a fibrous 
but incomplete septum only one inch above the anus, the result, apparently, 
of a malformation in the foetal development. Even when no malformation 
is present constipation in adult life can frequently be traced back to infancy. 

Usually it is best to commence the treatment of constipation by an enema, 
which softens and removes the hardened masses which have collected in the 
rectum and the adjacent part of the large intestine. For a young infant 
tepid water or tepid water containing a teaspoonful of glycerin suffices to 
produce an evacuation. No possible harm can result from rectal injections 
when properly employed ; and as they commonly act promptly, without 
causing pain and without any depressing effect, they constitute an import- 
ant part of the treatment in all forms of constipation. I have sometimes, in 
cases of habitual constipation, ordered for young infants the daily injection 
of three teaspoonfuls of sweet oil and one of castor oil. Injections should 
always be prescribed instead of medicine by the mouth when there is rea- 
son to believe that the cause of the constipation is mechanical, as from the 
great length and many loops in the sigmoid flexure. There are cases of con- 
stipation from this cause for which injections should be employed daily for 
many months, and if given gently, with a properly lubricated instrument, they 
ultimately give complete relief, and without producing any injurious effect. 
One of the meat broths or a gruel of some farinaceous substance may some- 
times be advantageously employed for the same purpose. 

In the common forms of constipation, in which the cause is feeble peri- 
stalsis or scanty intestinal secretions or the use of food of too constipating a 
nature, we should endeavor to render the ingesta more laxative. Professor 
Jacobi has recommended for this condition to give a lump of sugar dissolved 
in water at each nursing. I have employed the sugar of milk, given in half- 
teaspoonful doses, to young infants also at each nursing, or several times 
through the day if required. Manna dissolved in hot water is also an old 
remedy for the same purpose. Glucose, into which starch is converted in 
the process of digestion and also by the action of the diastase of malt, is like- 
wise laxative. The various foods of the shops which contain glucose derived 
from barley or other flour by the agency of malt, employed as directed by the 
late Baron Liebig, are therefore useful in the treatment of habitual consti- 
pation in infants. Of four constipated infants in the New York Infant 
Asylum to whom Horlick's " sugar of malt " was given, three were relieved. 
Any of the glucose preparations can be given quite freely to a constipated 
infant without impairing the digestive function or producing other ill-effect,, 
so long as no more than the normal evacuations are produced ; and I consider 
them among the best and safest of the foods for the relief of constipation in 
infants. But glucose or grape-sugar is only feebly laxative ; probably not 
more so than cane-sugar. 



TREATMENT. 159 

The ordinary purgatives stoulcl not be given habitually to relieve a con- 
stipated habit. They are likely to irritate the intestines, causing a catarrh, 
or else, the intestines becoming accustomed to their action, a large dose is 
required. If possible, the bowels should be kept open by dietetic and hygi- 
enic measures. A light oatmeal gruel, long boiled, mixed with salt and con- 
siderable sugar, given at or between the nursings, sometimes has the desired 
effect, especially if in addition to the salt it contain considerable sugar. We 
may aid in increasing the peristalsis and overcoming the constipation by the 
massage treatment over the bowels. The fingers, lubricated with any kind 
of oil. should rub and knead the abdominal surface, I have seen the best 
results from this treatment. Cold applications over the abdomen, so highly 
recommended b}^ Trousseau in adult cases, cannot be safely employed in 
infancy, especially in early infancy. A well-known remedy in adult cases 
is the use morning and evening of a tumblerful of cold water. Water 
may also be added in considerable quantity to the ingesta of the consti- 
pated infant. 

Although, as stated above, we deprecate the necessity of using habitually 
purgative medicines for constipation, sometimes they are required, but if a 
laxative remedy which aids in the nutrition be prescribed, there is no objec- 
tion to its use. Such a remedy is the following : 

R- Ol. morrrhuEe, ^iv; 

Aq. calcis, 
Syr. calcis lactophos., cici. ^ij. 

Shake bottle and give half a teaspoonful three times daily to young infants 
But this remedy, useful in some cases, in others disappoints our expectations. 
If it be necessary to employ one of the recognized purgatives, the safest and 
best in my opinion is calcined magnesia, given in the following formula : 

R. Magnesia calcinat., .^j ; 

Sacchari lactis, ^ij. Misce. 

Fifteen grains to a drachm, according to the age, may be given to infants, and 
repeated as may be found necessary. 

The newly-born infant when in health ordinarily has about three stools 
daily, but one free evacuation may be sufficient. We know that the function 
of defecation is, to a certain extent, under the control of habit. Adults who 
have evacuations at a certain hour feel the need of them each day as that 
hour arrives. We should endeavor to encourage this habit in infancy and 
childhood. 



CHAPTER V. 

TETANUS NEONATORUM. 

Tetanus or trismus is one of the most interesting diseases of infancy. 
It is one of the first in point of time in the long catalogue of fatal maladies. 
It occurs suddenly and unexpectedly in the robust as well as the feeble, almost 
certainly destroying life within a few hours under modes of treatment hereto- 
fore employed. It is more frequent in some localities and conditions of life 
than in others. In New York it is more common in infancy than tetanus at 
any other age, or, indeed, in all other ages, since the mortuary statistics of 



160 TETANUS NEONATORUM. 

this city exhibit a larger number of deaths from this disease in the first year 
of life than subsequently. Infantile tetanus occurs, with very few excep- 
tions, in the newly-born. 

Did we fully understand the pathology of diseases in the new-born, or 
could we more accurately ascertain the condition of organs at this age, doubt- 
less we should occasionally consider those phenomena which we now designate 
as a disease j9er .se, under the title tetanus, as symptoms of some other aflFection. 
But as tetanic rigidity and spasms in the new-born occur so abruptly, masking 
all other symptoms and ordinarily ending in death, without our knowing cer- 
tainly whether or not there is any antecedent disease, it seems proper that 
we should recognize the state in which such muscular rigidity occurs with 
such a rapid result as an independent affection. This explanation is required 
from the fact that I have added to the accompanying table one case from 
Billard which this observer relates under the head of spinal meningitis. In 
this case an infant three days old was attacked with convulsions. " His 
limbs were rigid and violently bent; the muscles of the face were in a con- 
tinual state of contraction." On the following day ''the convulsions con- 
tinued ; . . . . the body remained rigid, and the vertebral column, which the 
weight of the trunk will cause to bend with the greatest ease in a young 
infant, remained straight and immovable whenever the child was raised." At 
the autopsy, in addition to meningeal apoplexy, which is often present in those 
who die of tetanus infantum, a thick pellicular exudation was found upon the 
spinal arachnoid. There is, therefore, a strict accordance of the symptoms 
and history of this case with those which other observers describe as exam- 
ples of tetanus infantum ; moreover, as a satisfactory reason for including 
this case in our statistics, certain observers, as we shall see, have reported 
epidemics of tetanus in which meningitis was the principal lesion. 

Fatal Cases. 

Case 1. Male ; taken when three days old ; lived sixty hours. Labatt, Edin. 

Med. and Surg. Jour., April, 1819. 
" 2. Female ; taken when three days old ; lived forty hours. Ibid. 
" 3. Taken when five days old; lived fifty hours. Ibid. 
" 4. Taken when three days old ; lived one day. Ibid. 
" 5. Male ; taken when two days old ; lived two days. Billard, Treatise on 

Diseases of Children, Stewart's trans., p. 477. 
" 6. Male; taken when three days old ; lived two days. Komberg. 
" 7. Male ; taken when six days old ; lived ninety-three hours. Dr. Imlach, 

Month. Jour, of Med. Scl, Aug. 1850. 
" 8. Female ; taken "at five days ; lived four days. Caleb Woodworth, M. D., 

Boston Med. and Surg. Jour., Dec. 13, 1831. 
" 9. Negro; taken at seven days; lived twenty-four hours. P. C. Gaillard, 

M. D., Soidh. Jour, of Med. and Phar., Sept. 1846. 
" 10. Male; taken when seven days old; lived one day. Augustus Eberle, 

M. D., Missouri Med. and Surq. Jour., 1847. 
'' 11. Taken when seven days old. D. B. Nailer, N. 0. Med. Jour., Nov. 1846. 
" 12. Male; taken when three days old; lived one day. N. 0. Med. and Surg. 

Jour., May, 1853. 
" 13. Negro ; taken when three days old ; lived three days. Eobert H. Chinn, 

M. D., ^V. 0. Med. and Surg. Jour. 
" 14. Taken when two days old ; died in four hours after the doctor's visit. 

Ibid. 
" 15. Taken when seven days old ; lived one day. C. H. Cleveland, New 

Jersey Med. Rep., April, 1852. 
'' 16. Negro "; taken when seven days old ; death finally. Greenville Dowell, 

Amer. Jour, of Med. Sci., Jan. 1863. 
'' 17. Taken when twelve days old ; lived one day. Thomas C. Boswell, com- 
municated to Dr. Sims, Amer. Jour, of Med. Set., 1846. 



PERIOD OF COMMEXCEMEXT, 161 

Case 18. Taken when about five days old; died at about the age of nine days. 
B. R. Jones. Ibid. 

" 19. Taken at or soon after birth ; lived two davs. Dr. Sims, Arner. Jour, of 
Med. Sci., April, 1846. 

'' 20. Taken at the age of six days ; lived one day. Ibid. 

" 21. Taken when three days old ; lived two days. Ibid. 

" 22. Male ; taken at the age of eight days ; died in three hours. Communi- 
cated to the writer. 

'• 23. Taken at the age of twelve hours : lived two days. Communicated to 
the writer. 

*'• 24. Female ; taken when seven days old ; lived forty-five hours. The 
writer. 

•• 25. Male ; taken at the age of seven days ; lived forty-eight hours. Ibid. 

" 26. Female ; taken at the age of eight days ; lived three days. Ibid. 

'' 27. Female ; taken at the age of five days ; lived three days. Ibid. 

"' 28. Female ; taken wdien four days old ; lived two days. Ibid. 

" 29. Taken when six days old ; died next day. Ibid. 

" 80. Taken when five days old ; lived twenty-four hours. Ibid. 

" 31. Taken when eight clays old; lived two days. Ibid. 

" 32. Male; taken when five davs old; lived one day. Ibid. 



Favorable Cases. 

Case 1. Xegro; female; taken when three davs old; recovered in a few days. 

Robert S. Baily, Charleston Med. Jour, and Bev., Nov. 1848. 
2. Negro; taken at eleven davs; recovered in fifteen davs. W. B. Lindsay, 

N. 0. Med. Jour., Sept. 1846. 
^' 3. Negro; taken when ten days old; recovered in thirty-one days. P. C. 

Gaillard, Charleston Med. Jour, and Rev., Nov. 1853. 
'" 4. Male ; taken at the ao-e of eisfht davs ; recovered in twentv-eight days. 

Ibid. 
'* 5. Negro ; taken at seven days ; recovered in fifteen days. Augustus 

Eberle, Missouri Med. and Surg. Jour., 1847. 
'• 6. Taken when eight days old ; recovered in four weeks. Furlonge, Edin. 

Med. and Surg. Jour., Jan. 1830. 
*' 7. Taken at the age of one week ; recovered in two davs. Dr. Sims, Amer. 

Jour of Med. Sci., April, 1846. 
'' 8. Female ; taken at the age of three days; recovered in five weeks. The 

writer. 

Period of Co^imencement. — Finckh.^ who saw cases of tetanus of the 
newly-born in the Stuttgart Hospital, states that it began in 1 case on the 
second day after birth, in 8 on the fifth, and in 7 on the seventh. 

Professor Cederschjold of Stockholm treated 45 cases in hospital practice 
in 1834, and in these cases it usually commenced between the ages of four 
and six days. Copland'^ says that it generally commences in the first seven 
or nine days after birth, and rarely later than the fourteenth. Romberg 
states that it commences between the fifth and ninth days. In 200 cases 
observed by Reicke in Stuttgart in the course of forty-two years, it was 
never found to commence before the fifth, rarely after the ninth, and never 
after the eleventh day. Schneider says that the disease occurs oftenest 
between the second and seventh, and rarely after the ninth, day. In 6 cases 
reported by Dr. C. Levy of Copenhagen it began in 2 on the third day, in 2 
on the fifth, and in 2 on the sixth. Dr. Greenville Dowell.^ who has seen 
much of tetanus neonatorum among the negroes in Mississippi and Texas, says 
it is almost sure to come on between the fifth and twelfth days after birth. 
In the 40 cases embraced in the above table the disease began as follows : 

^ Heckers Annalen, vol. iii. No. 3, p. 304. ^ Medical Dictionary. 

^ Amer. Jour, of Med. Sci., Jan., 1863. 

11 



162 TETANUS NEONATORVM. 

Age. Cases. 

Under two days 2 

Two days 1 

Three days 9 

F'our days 2 

Five days 6 

Six days .... 3 

Seven days 8 

Eight days ... ' 6 

Ten days 1 

Eleven days 1 

Twelve days 1 

Very rarely, as will be seen hereafter, tetanus begins at or so soon after 
birth that it may properly be called congenital. 

Frequency in Certain Localities. — Tetanus neonatorum occurs prob- 
ably in all countries, but it does not greatly increase the mortality except 
in certain localities. Some of the British and Continental physicians, whose 
observations of disease have been ample, confess that they have seen so few 
cases that they have almost no personal knowledge of this malady. On the 
other hand, there are or have been places in every zone where it is or has 
been so prevalent as to sensibly check the increase of population. The atten- 
tion of the profession more than a half century since was directed to the 
prevalence of tetanus in the island of Heimacy, off the coast of Iceland. 
On this island scarcely an infant escaped, while on the mainland scarcely 
one was affected. Heimacy, the product of volcanic action, of small extent 
and almost destitute of vegetation, supports a scanty population. The inhab- 
itants live chiefly on the flesh and eggs of the sea-fowl, and are filthy and 
degraded in their habits. About the year 1810 the Danish government 
deputed the landphysicus of Iceland to visit Heimacy and ascertain the 
nature of the disease which was so destructive to the infants. Although 
this gentleman, from his brief stay, saw no case himself, he obtained interest- 
ing particulars in reference to the disease from the priests and parents. At 
this time scarcely an infant escaped. Again, according to Dr. Schleisner, 
whose report in reference to the same locality was published forty years later, 
tetanus was still the most fatal of ail infantile maladies. 

Tetanus neonatorum is also represented as very fatal in the island of St. 
Kilda, off the coast of Scotland. In the temperate regions of America and 
Europe cases are not frequent, except occasionally in the poor quarters of 
cities, in foundling hospitals, and rarely in country towns where the condi- 
tions are favorable for its occurrence. The records of the Dublin, Stutt- 
gart, and Stockholm lying-in asylums furnish many cases. In the town of 
Fulda, Germany, in 1802, Dr. Schneider saw 6 cases in fourteen days, while 
a midwife in the same place stated that she had seen more than 60 in nine 
years. 

But the greatest mortality from tetanus neonatorum is in the warm climates 
both of the Eastern and Western hemispheres. In the West Indies, the south- 
ern portion of the United States, the equatorial regions of South America, 
and in the islands of Minorca and Bourbon, it has in many localities been the 
most frequent and fatal of infantile maladies. 

It is an interesting fact that in the warm regions of the United States the 
victims are chiefly negro infants. L. S. Grier, M. D.,^ of Mississippi says: 
" The first form of disease which assails the negro among us is trismus. The 
mortality from this disease alone is very great. No statistical record, we sup- 
pose, has ever been attempted, but from our individual experience we are 
almost willing to affirm that it decimates the African race upon our planta- 
^ N. 0. Med. and Surg. Jour., May, 1854. 



CAUSES. 163 

tions within the first week of independent existence. We have known more 
than one instance in which, of the births for one year, one-half became the 
victims of this disease, and that.. too. in spite of the utmost watchfidness and 
care on the part of both phinter and physician. Other phices are more for- 
tunate, but all suffer more or less ; and the planter who escapes a year with- 
out having to record a case of trismus nascentium may congratulate himself 
on being more favored than his neighbors, and prepare himself for his own 
allotment, which is surely and speedily to arrive." Dr. Wooten^ says: -^ It 
is a disease of fatal frequency on the cotton plantations in this section of 
Alabama." He has, however, never seen a white child aifected with it. 

While tetanus infantum prevails in regions wide apart and presenting 
very diverse climatic conditions, there is a similarity as regards the personal 
and domiciliary habits of the people who suffer most from its occurrence. It 
occurs chiefly among those who are filthy and degraded in their habits — who 
live, either from choice or necessity, in neglect of sanitary requirements. 
This fact aids us in an understanding of the 

Causes. — That uncleanliness and impure air are causes of tetanus is as 
fully demonstrated as most facts in the etiology of diseases. The attention 
of the profession was forcibly directed to this cause by Dr. Joseph Clarke in 
a paper read before the Royal Irish Academy in 1789. This physician was 
in charge of the Dublin Lying-in Asylum, and had rightly concluded that 
the mortality among the new-born infants was due to imperfect ventilation. 
Through his advice, apertures (twenty-four inches by six) were made in the 
ceiling of each ward ; three holes, an inch in diameter, were bored in each 
window-frame ; the upper parts of the doors leading into the gallery were also 
perforated with sixteen one-inch apertures, and the number of beds was 
reduced. The results of these simple sanitary regulations may be seen from 
Dr. Clarke's own statement. He says: '-At the conclusion of the year 1782, 
of 17.650 infants born alive in the Lying-in Hospital of this city, 2944 had 
died within the first fortnight — that is, nearly every sixth child."' The disease 
in nineteen cases out of twenty was tetanus. After the wards were better 
ventilated — namely, from 1782 till the time of the preparation of Dr. Clarke's 
paper: — 8033 children were born in the hospital, and only 419 in all had died, 
or about one in nineteen. So impressed was Dr. Evory Kennedy, who at a 
later period had charge of the same asylum, with the belief that Dr. Clarke 
had discovered the true cause, and had been able in great measure to prevent 
it, that he enthusiasticall}^ writes : " If we except Dr. Jenner, I know of no 
physician who has so far benefited his species, making the actual calculation 
of human life saved the criterion of his improvements." The cases occur- 
ring in my own practice have almost all been in tenement-houses, where 
habits of cleanliness are not observed, and I have not yet seen in the prac- 
tice of others nor heard of a case which occurred in the better class of dom- 
iciles. The statements of physicians in the Southern States, who speak from 
extensive observation among negroes, are strongly corroborative of the belief 
that the disease is in great measure due to uncleanliness and lack of pure air. 

Dr. G-reenville Dowell of Texas states that he has been able to trace tetanus 
infantum to the bed-clothes, saturated with excrementitious matters, which 
are found in the negro cabins. In a paper published by Prof. John M. Wat- 
son - the frequency of this disease among negroes is accounted for as follows : 
'' When called to see their children we find their clothes wet around their hips, 
and often up to their armpits, with urine The child is thus pre- 
sented to us. when, on examination, we find the umbilical dressings not only wet 
with urine, but soiled, likewise, with feces, freely giving off an offensive 

^ X 0. Med. and Surg. Jour., Mar, 1846. 
"^Nashville Jour, of Med. and Surg., June, 1851. 



164 TETANUS NEONATORUM. 

urinous and fecal odor, combined at times with a gangrenous fetor arising 
from the decomposition, not desiccation, of the cord." 

Another cause is believed to be some irritation in the intestines, as from 
retained meconium. Observers in the Southern States and elsewhere occa- 
sionally mention this as a cause. In one case treated by myself there was 
obstinate constipation immediately before the attack, and in another diarrhoea 
preceded and was the only apparent cause. 

In certain cases the assignable cause is exposure to wet or cold or to a 
variable temperature, which, it is known, occasionally produces tetanus in the 
adult. Prof. Cederschjold attributed the epidemic which he observed in 
Stockholm to a sudden change of temperature from hot weather in May to 
frosty in June. In a case related by Dr. P. C. Gaillard ^ the disease com- 
menced as follows : The nurse came in with wet apron and clothes in the 
evening ; a short time after she had taken the child into her lap it sneezed 
violently two or three times. At 10 p. M. tetanus began. In certain local- 
ities on the Continent, where there are no parish churches, the frequent occur- 
rence of tetanus has been attributed by physicians to the practice of carrying 
infants to a distance to be christened, thus exposing them to winds. In this 
city I have observed tetanus after a similar exposure. The influence of the 
weather in the production of tetanus of the new-born is also shown by 
facts observed in the Stuttgart hospital. In an aggregate of 25 cases 
treated in that institution, all but 3 occurred in the cold months. In the 
island of Cayenne, at a hamlet surrounded by mountains and dense forests, 
tetanus attacked only one in every twelve of the new-born infants. After a great 
part of the forests had been cut down, so as to allow access to the cold sea- 
winds, almost all the new-born infants fell victims to tetanus (Insel. Cayenne). 

Hein relates that a citizen of Berlin lost, successively, two children with 
tetanus soon after birth. When the second child fell ill he observed that its 
cradle was exposed to a current of air. At the third accouchement the 
position of the cradle was changed and the infant escaped. Exposure to wet 
and cold has been long recognized as a cause of the disease. According to 
Sauvages. " Hie morbus hieme et cum aura humida saepius advenit quam 
sicca sestate." ^ 

The causes of infantile tetanus enumerated above may be proximate or 
remote, may produce the disease by their direct effect on the system or indi- 
rectly by causing a pathological state which in turn leads to the development 
of the disease. There are other direct causes — namely, organic affections. 
In the bodies of the new-born who die of tetanus lesions are observed which 
doubtless result from the spasms. Again, others are found which from their 
nature could not be a result, and which, being observed in different cases, are 
to be regarded as causes. The most frequent of such lesions is inflammation 
of the umbilicus or umbilical vessels. 

Moschion, who lived in the first century of the Christian era, stated in 
writings still extant that stagnant blood in the umbilical vessels sometimes 
produced dangerous disease in the new-born infant, and it is supposed, though 
this is doubtful, that he referred to tetanus. In modern times the attention 
of the profession has been more particularly directed to this cause by a paper 
published by Dr. Colles.^ The observations contained in this paper were 
made in the Dublin Lying-in Hospital during a period of five years. In each 
of these years he witnessed from three to five post-mortem examinations in cases 
of infantile tetanus, and the lesions, he states, were in all much alike, as fol- 
lows : The floor of the umbilical fossa was lined by a membrane apparently 
formed by suppurative inflammation, and in the centre of this fossa was a large 

^Southern Jour, of Med. and Pharmacy, Sept., 1846. 

'' Nosol. Method., vol. i. p. 531. ' ^ j)ubUn Hospital Reports, vol. i., 1818. 



CAUSES. 165 

papilla. This papilla consisted of a soft yellow substance, apparently the prod- 
uct of inflammation, and in all the cases the umbilical vessels were in contact 
with this substance and were pervious. In a few instances superficial ulcera- 
tions were found near the mouth of the umbilical vein, and occasionally the 
skin surrounding the umbilicus was raised. The peritoneum covering the vein 
was highly vascular, often not to a greater distance that an inch above the 
umbilicus, but sometimes as far as the fissure of the liver. The peritoneum 
in the course of the umbilical arteries presented the inflammatory appearance 
in still greater degree, sometimes as far as the sides of the bladder. The 
connective tissue lying along the arteries and urachus anteriorly was loaded 
with a yellow watery fluid. The inner surface of the umbilical vein was not 
inflamed, but its coats in general were thickened. On slitting open the arte- 
ries a thick yellow fluid, resembling coagulable lymph, was found within their 
coats, and in all cases these vessels were thickened and hardened as far as 
the fundus of the bladder. 

Dr. Finckh, who observed 25 cases in the Stuttgart Hospital, believes that 
the most frequent cause was suppuration or ulceration of the umbilical cord. 
In 10 of the 25 cases the navel was dry and cicatrized ; in the remainder it 
was either wet or swollen, with a bluish-red inflamed edge at the margin of 
the navel ; a dirty viscid pus covered the umbilical depression. 

Dr. Levy, physician of the Foundling Hospital in Copenhagen, attended 
22 cases in that institution in 1838 and 1839. Of these, 20 died, and 15 
were examined carefully after death. In 14 there were decided marks of 
inflammation of the umbilical arteries, especially of those portions lying 
along the urinary bladder ; in several cases the peritoneum over the arteries 
was much injected, and in 3 adherent either to the omentum or intestine by 
coagulable lymph ; the coats of the arteries were thickened, their cavities 
dilated and containing dark reddish-brown or greenish puriform matter, always 
fetid. Sometimes the arterial tunica interna was found ulcerated and absent 
in places, and there was spongy thickening of the subjacent connective tis- 
sue. In 2 cases the ulcerative process had extended from the tunica interna 
to the peritoneum, and there was a deposit of thick ichorous matter around 
the ulcer ; in 1 case both arteries were so softened that their coats were 
scarcely distinguishable, and in another these vessels had become gangre- 
nous. The appearance of the umbilicus was unchanged in -4 cases ; in 10 
th3 fundus was red and filled with puriform fluid, which quickly reappeared 
when removed, and, in general, shortly before death the navel presented a 
greenish color. 

According to Romberg, Dr. Scholler made post-mortem examinations in 
18 cases of tetanus infantum, and in 15 found inflammation of the umbilical 
arteries. These vessels were swollen near the bladder, in 1 case to the diam- 
eter of four lines, and were found to contain pus. The lining membrane was 
eroded or covered with an albuminous exudation. Both arteries were not 
always equally inflamed, and in 3 cases, only 1 was afi'ected. 

Schneeman ^ found minute points of suppuration in the umbilical vein in 
8 cases, and pus throughout the course of this vessel in 1. 

The observations mentioned above were made, for the most part, in hos- 
pitals on th3 Continent, but similar observations have been mado in private 
practice. M. Borian ^ of the isle of Bourbon says that he has found in every 
case inflammation around the umbilicus. Dr. John Furlonge,^ who resided 
at St. John's, Antigua, attributes the disease to improper dressing of the 

^ Holsche-i^s Annalen, vol. v. p. 484, 1840. 
^ Gazette medicale. Paris. July 11, 1841. 
^ Edin. Med. and Surg. Jour'.. -Jan., 1830. 



166 TETANUS NEONATORUM. 

umbilicus. The same opinion is expressed by Mr. Maxwell,^ who also saw 
the disease in the West Indies. Dr. Ransom ^ states in a communication to 
Prof. John M. Watson that he has never seen a case of tetanus of the new- 
born in which the umbilicus was healthy. In a case related by Robert S. 
Bailey^ there was a hard scab on one side of the umbilicus, and this part was 
much distended. A discharge followed the removal of the scab, and the 
child recovered. In a favorable case related by W. B. Lindsay^ the umbili- 
cus was tumid and not disposed to heal. Dr. H. 0. Wooten ^ attributes the 
disease to the condition of the umbilicus and umbilical vessels, and states 
that he has found the umbilicus gangrenous. A case has been reported in 
which the umbilical vessels were blocked up by purulent matter.'^ Robert 
H. Chinn, M. D.,'' of Brazoria, Texas, believes one cause of the disease to be 
improper tying and management of the umbilical cord, by which a diseased 
state is produced which extends to the umbilicus and thence to the viscera. 
At a meeting of the Obstetrical Society of Edinburgh, held April 24, 1850, 
Dr. Imlach related a case in which there was a dark and gangrenous appear- 
ance on the integument around the umbilicus, and the peritoneum underneath 
was also dark, but not inflamed ; umbilical vein healthy ; a little fibrin in the 
left umbilical artery ; right umbilical artery much diseased ; its two inner 
coats apparently destroyed, and in their place a yellow pultaceous slough in 
which pus-globules were discovered with the microscope. 

It is evident that the pathological state of the umbilicus and umbilical 
vessels described above, and which has been noticed by so many observers 
in different countries, cannot result from the tetanus. It is possible that the 
puriform substance noticed in the umbilical vessels was disintegrated fibrin, 
which had coagulated at the time of ligation of the cord, and the cells seen 
by Dr. Imlach and others may sometimes have been white corpuscles still 
remaining from the stagnated blood.^ Still, the evidences of inflammation, 
in at least a part of the cases related above, were of a positive character. 

The belief that umbilical lesions occasionally cause tetanus infantum com- 
ports with the well-known traumatic causation of tetanus in the adult. This 
belief is strengthened by the fact which will appear farther on in our remarks 
that tetanus of the new-born, from being frequent in certain localities, has 
become infrequent through greater care in dressing and managing the umbil- 
ical cord. 

But there are cases of tetanus infantum in which there is no disease in 
or about the umbilicus. Dr. Finckh of Stuttgart examined the umbilical 
vessels in eleven cases without discovering any pathological change. Dr. 
Samuel B. Labatt,^ master of the Dublin Lying-in Hospital, published a 
paper entitled ''An Inquiry into the Alleged Connection between Trismus 
Nascentium and Certain Diseased Appearances in the Umbilicus." This 
paper was designed as a reply to the essay of Dr. Colles. Dr. Labatt relates 
several cases in which there was uo disease of the umbilicus and umbilical 
vessels, and others in which the disease was so slight that it probably pro- 
duced no injurious effect on the health of the child. Dr. James Thomp- 
son,^^ who spent considerable time in the tropical regions, says : " I have 
myself examined nearly 40 cases of infants that have sunk under this com- 
plaint. In many I have looked at no other part than the navel, and have 

^ Jamaica Phys. Jour., copied into the London Lancet, April 11, 1855. 
■'' Nashville Jour, of Med. and Surg., June, 1851. 
=* Charleston Med.' Jour, and Rev., Nov., 1848. 

^ N. O. Med. and Surg. Jour., Sept., 1846. ^ Jhid., May, 1846. 

« Ibid., May 1, 1853. ^ Jbid., Sept, 1854. 

^ Virchow's C'ellul. Pathol. ^ Edin. Med. and Surg. Jour., April, 1819. 

^0 Ibid., Jan., 1822. 



CA USES. 167 

found it in all states — sometimes perfectl}' healed, especially if the infants 
had lived several days ; at other times a simple clean wound, When death 
occurred on the fifth or sixth day the wound was frequently in a raw state. 
I never yet saw it in a sphacelated condition." This writer concludes from his 
observations that there are cases in which the cause is located elsewhere than 
in the umbilicus or umbilical vessels. Dr. John Breen ^ remarks : " From 
dissections .... we have never been able to discover any peculiar morbid 
appearance which would justify us in offering any explanation of the pathol- 
ogy of the disease.'' In my own cases there was no evidence of disease of 
the umbilicus or umbilical vessels, so far as could be ascertained by external 
examination, and in one (No. 32) a careful post-mortem examination dis- 
closed no lesion of these parts. 

The inference from the above observations is that, although umbilical 
disease ma}' be an occasional, probably not infrequent, cause of tetanus 
neonatorum, cases occur in which such disease is not present, and we must 
look for the cause elsewhere. From the nature of tetanus neonatorum, the 
cerebro-spinal axis has been from time to time examined in those who have 
died of this malady, and occasionally sufficient cause has been found in this 
part of the system. 

I have alluded in another connection to a case from Billard in which 
tetanic rigidity occurred in an infant three days old as the result of spinal 
meningitis. That tonic spasms not infrequently occur in older children in 
consequence of meningeal inflammation is well known, and in some of the 
reported epidemics of infantile tetanus meningitis was really present, and 
was doubtless the cause of the tonic spasms. Such an epidemic was 
observed by Professor Cederschjold in Stockholm in 1834. Within a few 
months he treated 42 cases, and in addition to the lesions which are known 
to result from tetanus, there was found in the bodies examined a fibrinous exu- 
dation at the base of the brain. Finckh of Stuttgart made 20 post-mortem 
examinations of those who had died of this disease, and in 9 found spinal 
meningeal inflammation. 

Meningitis in the new-born is. however, rare, and we must regard it as 
exceptional in cases of tetanus. 

In 1846 the late Dr. Marion Sims published a paper designed to show 
that tetanus neonatorum results from injury of the brain produced b}' 
depression of the occipital bone ; but I am not aware that this theory has 
any adherents at the present day. It is true that occipital depression quick- 
ly occurs in cases of tetanus, but it appears to be due mainly to the rapid 
emaciation of the brain and diminished cerebral circulation which attend 
this disease. 

Finckh made post-mortem inspection of 20 cases in the Stuttgart Hospital, 
the bodies at death having been placed on their faces in order to prevent any 
deceptive appearance from the gravitation of blood. In 4 he failed to detect 
any alteration in the spinal cord or its membranes, but in the i-emaining 16 he 
found effusion of blood in considerable .quantity the whole length of the 
spinal cord between the bony walls and the dura mater. It should be stated, 
however, that spinal meningeal inflammation was present in 9 of the 16, 
though the extravasation did not probably result from the inflammation, but 
from the tetanus. The blood in Finckh's cases was very dark — sometimes 
fluid, at other times coagulated. In 1 case no change was observed in the 
appearance of the brain or its membranes. In the remaining 19 more or 
less extravasated blood was found on the surface of the brain or in its inte- 
rior. The substance of the brain was healthy, as also its membranes, except 
the congestion. The only abnormal appearance observed in the thoracic and 
^ Bub. .Jour, of Med. and Chem. ScL, Jan., 1836. 



168 TETANUS NEONATORUM. 

abdominal viscera was strong contraction of some portion of the intestinal 
tube in five cases. Dr. West says : " The most frequent post-mortem 
appearances in these cases '" — referring to tetanus neonatorum — " and that 
which I found in the bodies of all the four children whom I observed, con- 
sist of effusion of blood, either fluid or coagulated, into the cellular tissue 
surrounding the theca of the cord. Conjoined with this there is generally a 
congested state of the vessels of the spinal arachnoid, and sometimes an 
effusion of blood or serum into its cavity. The signs of congestion about 
the head are less constant, though much oftener present than absent, and 
sometimes existing in an extreme degree ; while in one instance I found not 
merely a highly congested state of the cerebral vessels, but also an effusion 
of blood in considerable quantity between the skull and dura mater, and 
also a slighter effusion into the arachnoid cavity." Dr. Weber of Kiel also 
placed on their faces infants who had died of tetanus, and without exception, 
found injection of the capillaries of the cord and spinal meninges and 
extravasation of blood. M. Matusynski, according to Bouchut, " has 
observed effusions of blood of variable quantity in the cerebral pia mater, in 
the ventricles, and in the choroid plexuses, with considerable injection of the 
membranes of the brain. He has also seen serous infiltration beneath the 
arachnoid and serous effusion into the ventricles, accompanied by a diminu- 
tion of the consistence of the cerebral substance." In two cases examined 
by myself there was intense injection of the cerebral meninges and of the 
meninges of the upper part of the spine, but no extravasation was noticed. 
The spinal canal was not opened. In a third case, in which the spinal canal 
was opened, there was extravasation in addition to the congestion ; this was 
especially observed along the spinal theca. 

Dr. H. 0. Wooten ^ states that he has made several post-mortem examina- 
tions, and has found the pathological appearances as uniform as in any other 
disease, as follows : '• Engorgement of the substance of the brain and of the 
meninges lining the base of the brain, the medulla oblongata, and spinal 
marrow ; liver congested." 

In a case related by Dr. Imlach before the Edinburgh Obstetrical Society, 
April 24, 1850, the upper part of the lungs was healthy, the posterior por- 
tion congested and containing many dark points ; heart and liver healthy ; 
small intestines of a light-brown color ; stomach and large intestines pallid ; 
there had been umbilical hemorrhage. 

Romberg states that he found in a child whose death occurred from this 
disease such intense congestion of the veins and sinuses of the brain that a 
slight touch and the removal of the cranial bones produced extravasation of 
the partly coagulated and partly fluid blood. Dr. Scholler, on the other 
hand, found extravasation of blood in the spinal canal in only 1 case in 
18. 

It is seen from the above observations that tetanus neonatorum is ordi- 
narily accompa,nied by extreme passive congestion of the internal organs, 
including the cerebro-spinal axis and its meningeal investment. The embar- 
rassment of respiration and the retarded circulation of blood consequent on 
the tetanic rigidity afford sufficient explanation of this state of the vessels. 

We have stated at length the condition of the various organs in those 
who have perished from tetanus, as reported by competent observers in differe-nt 
localities, so that, if possible, light might be thrown on the causation of this 
interesting and fatal malady. But observations more recent than those given 
above appear to show that tetanus is, sometimes at least, a microbic disease 
and is communicable by inoculation. Dr. E. Riper of Greifswalde (^Cev- 
tralhlatt fiir Medicin^ Oct. 15, 1887) states that parts of the navel removed 

1 N. 0. Med. and Surg. Jour., May, 1846. 



CAUSES. 169 

with sterilized instruments from an infant having tetanus communicated the 
disease by inoculation to six mice. Guinea-pigs inoculated with a little of 
the tissue taken from the wounds in the dead mice took tetanus five days 
later. Dr. Beumer (Berlin. Mia. Woch., No. 30, 1887) also states that he 
communicated tetanus to mice and guinea-pigs by inoculating them with tis- 
sue from the umbilicus of an infant that died of tetanus. Recently, Ver- 
neuil of France has published two papers in which he cites instances appa- 
rently showing that tetanus is sometimes derived from the lower animals, 
especially the horse, and is in other instances communicated by man to the 
lower animals. Verneuil cites the following interesting example showing 
the mode of infection : A newly-born child died of tetanus. Its mother 
took a nurse-child, which soon perished from the same disease. Fifteen days 
after, the family horse contracted the disease, which was tedious, but it ended 
favorably. Before it recovered the woman also contracted tetanus, which 
was protracted, but not fatal. Dr. T. B. Adams, physician to the Foochow 
Native Hospital, states that tetanus is rare in Southern China, but a patient 
died of it in one of the hospital wards on Oct. 1, 1887. On Oct. 8th a 
patient with bleeding piles was assigned to the same little room in which 
the patient with tetanus had died, and the piles were ligated two da3^s later. 
Nine days after the operation tetanus commenced, and was fatal. In 1886, 
Rosenbach produced tetanus in two guinea-pigs by introducing under their 
skin a little gangrenous substance from the sore of a patient with tetanus. 
In 1887, Bonome had under observation three patients with tetanus who 
were wounded by the falling of a church. In the fetid wounds of these 
patients he discovered, in addition to numerous other bacteria, a slender 
bristle-like bacillus, thick, straighter, and longer than the tubercle bacillus, 
and with a rounded extremity, so as to resemble a pin. He was unable 
to cultivate it, but inoculations with the pus which contained it caused 
tetanus. 

Other observations and experiments similar to the above might also be 
stated, so that there is little doubt that the tetanus of animals and that of 
man are identical, and that this disease is inoculable and therefore infectious. 
Dr. E. 0. Shakespeare in a recent paper on traumatic tetanus arrives at the 
following conclusions : " Traumatic tetanus of animals and of man is at least 
sometimes, if not constantly, an infectious specific affection, due to the action 
of a specific infectious virus which exists in the tissues around the seat of 
the infection, in the blood, and in the central cerebro-spinal system." 

The observations detailed above certainly lend strong support to the 
theory that tetanus is produced b}^ a microbe, but it is stated that Brieger 
has succeeded in isolating a ptomaine produced in the cultures of the bacillus 
of Rosenbach, which ptomaine has the formula Ci3H3ox\g.20i, and, injected 
hypodermically in animals, produces tetanic symptoms (^Annual of the Univer. 
Med. Sci., vol. iii., 1889). But even if it be shown that the immediate cause 
of tetanus is a ptomaine, the theory of its microbic origin is, not invalidated, 
since the ptomaine results from microbic action. That the cause is a micro- 
organism, and that it may reside in the soil, has been shown by the recent 
observations of Prof. Wm. H. Welch of Johns Hopkins University, who in 
his address before the American Medical Association at Newport, June 28, 
1889, said : " Among the pathogenic bacteria which have their natural home 
in the soil, the most widely distributed are the bacilli of malignant oedema 
and thosG of tetanus. I have found some garden earth in Baltimore extremely 
rich in tetanus bacilli, so that the inoculation of animals in the laboratory 
with small bits of this earth rarely fails to produce tetanus." But whether 
this disease is produced directly by the agency of a microbe, or by a ptomaine 
resulting from microbic action, or occasionally by other causes distinct from 



170 TETANUS NEONATORUM. 

either microbe or ptomaine, it cannot be doubted that the cause is the same 
in tetanus neonatorum as in that of the adult. We have seen that many 
observers have regarded uncleanliness as the common cause of tetanus 
neonatorum, since they have remarked its occurrence when the umbilical 
dressing was filthy and offensive or the apartments or the surroundings dirty. 
These observations are compatible with the theory of the microbic origin of 
tetanus, for microbes find a nidus and are propagated in greatest abundance 
where insanitary conditions exist. 

Symptoms. — In many cases premonitory symptoms are absent or are so 
slight as to escape notice. In some patients fretfulness precedes the attack, 
but no more than is often observed in those who continue in good health. 
The first symptom which alarms the parents and shows the grave nature of 
the commencing disease is inability to nurse or evident pain and hesitation in 
nursing. Commencing with rigidity of the masseters, the disease gradually 
extends to the other voluntary muscles, and in the course of a few hours the 
muscles of the limbs as well as of the trunk are involved. Persistent mus- 
cular contraction, which is the pathognomonic feature of infantile tetanus, is 
developed not fully in the beginning, but by degrees in each affected muscle, 
so that it is not till after the lapse of several hours, perhaps even a day, that 
the greatest amount of rigidity is attained. Therefore in the commence- 
ment of the disease the limbs can be flexed and the jaw pressed open 
more readily than at a subsequent stage, though with manifest pain to 
the infant. 

During the period of maximum rigidity the jaws are fixed almost immov- 
ably, often w^ith a little interspace between them, against which the tongue 
presses and in which frothy saliva collects. • The head is thrown backward 
and held in a fixed position by the stiffness of the cervical muscles. The fore- 
arms are flexed ; the thumbs are thrown across the palms of the hands, and 
are firmly clenched by the fingers ; the thighs are drawn toward the trunk ; 
the great toes are adducted and the other toes flexed. Occasionally opisthot- 
onos results from the extreme contraction of the dorsal and posterior cervical 
muscles. The infant can sometimes be raised without any yielding of the 
muscles by the one hand under the occiput and the other under the heels. 

The rigidity is liable to variation in its intensity even after the full devel- 
opment of the disease. If the infant be quiet, especially if asleep, the mus- 
cles are partially relaxed to such an extent sometimes, in the first stages of 
the complaint, that the features have a placid and natural expression, though 
only for a short time. Frequent exacerbations occur in the muscular con- 
traction, sometimes without any apparent cause, and sometimes produced by 
anything which excites or disturbs the child. Attempts to open the lips or 
jaws or eyelids or to bend the limbs, blowing on -the face, or even crawling 
of a fly upon it, occasion the paroxysms. 

During the paroxysm the eyelids are forcibly compressed, as well as the 
lips, which are either drawn in or are pouting ; the forehead and cheeks are 
thrown into wrinkles and the physiognomy is indicative of great suffering. 
The unnatural positions of the trunk and limbs which result from muscular 
contraction are increased for the moment ; the head is more forcibly thrown back 
and the limbs more strongly flexed. The muscular movements which occur 
during the paroxysms are sometimes described as clonic spasms. There is 
indeed occasionally some quivering of the limbs, and yet, as I have on differ- 
ent occasions noticed, so far from the muscular action being a clonic spasm, 
it is clearly tonic and is intensified during the paroxysm. In fatal cases the 
paroxysms occur more and more frequently until the period of collapse. 

The crying of the child affected by tetanus is never loud, however great 
the suffering. It is variously described by writers as " whimpering " or 



PROGNOSIS. 171 

" whining." It is of this suppressed character in consequence of the rigid 
state of the respiratory muscles and their imperfect movement. 

During the exacerbation respiration is suspended, or so imperfect and the 
circulation so retarded that the surface becomes of a deep-red. almost livid, 
color. Sometimes epistaxis occurs, affording partial relief to the congestion, 
and sometimes, though less frequently, the blood forces itself from the con- 
gested liver along the umbilical vein and escapes from the umbilicus. The 
intense passive congestion consequent on the tetanic spasm is general through- 
out the system, but extravasation of blood appears to be more common around 
the brain and spinal cord than elsewhere. 

The frequency of the pulse and respiration varies in different cases and 
at different stages of the same case. They are often somewhat accelerated, 
but at other times are natural, or are even slower than in health.' 

While the appetite of the infant, to appearance, is not diminished, the 
pain which it experiences in nursing is such that alimentation is necessarily 
deficient. It can be fed with a spoon for a time after it ceases to take food 
in the natural way, but artificial feeding soon fails. The milk placed in its 
mouth is in great part pressed back through the violence of the spasm which 
is induced by the attempt to feed it. 

In consequence of imperfect nutrition the infant rapidly wastes away. 
There is no other disease, except the diarrhoea! affections, in which the ema- 
ciation is so rapid. In a case related by Dr. W. B. Lindsay^ the record states 
that '• the infant was fat three days before, but was now emaciated." Rom- 
berg, who saw tetanus neonatorum in European hospitals, and Robert H. 
Chinn^ of Texas, both speak of the rapid emaciation. The trunk and extrem- 
ities lose their fulness and the features become pinched. Several observers 
have noticed the appearance of miliaria in this reduced state of system, 
especially around the shoulders, and sometimes a decidedly icteric hue 
appears on the skin. 

The condition of the intestines is not uniform. They may be relaxed, 
particularly if the disease be due to some irritation in them ; in other cases 
the stools are natural or constipated. 

It is often difficult to ascertain the state of the eyes, since attempts to 
open the eyelids bring on spasms and cause firm compression of the lids 
against each other. According to Sir Henry Holland, one of the first symp- 
toms which occurred in cases on the island of Heimacy was strabismus, with 
rolling of the eyes. But this statement must be received with caution, since 
these cases were not seen by any physician and the information was obtained 
from the parents and priests. If true, the proximate cause of the disease in 
Heimacy would seem to be located in the cerebro-spinal axis. Contraction 
of the pupils commonly occurs in the stage of collapse. 

Mode of Death. — Death in infantile tetanus may occur from apnoea in 
the paroxysms, from extreme congestion of the cerebral vessels, or apoplexy ; 
and, lastly, it may occur from exhaustion. The last mode is probably the 
most frequent. 

Prognosis. — All writers till recently agree that tetanus of the infant 
rarely terminates favorably. Cullen attributes the ignorance of physicians 
in regard to this disease to the fact that it is so little amenable to treatment 
that they are not usually summoned to attend those affected with it. In the 
island of Heimacy. of 185 cases occurring during a series of years about the 
commencement of the present century, not one survived ; and in the same 
locality, at Westmannoe, a small islet, 64 per cent, of all the infants born 
died of trismus (report of Dr. Schleisner). Similar statements in regard to 
the mortality of tetanus infantum are given by physicians in the Southern 

1 JV. 0. iMed. Jour., Sept., 1846. ^ ^r q j^j^^_ ^^^^^ ^^^^,^^ j^^^,^^ ^^^^^ 2g54_ 



172 TETANUS NEONATORUM. 

States. Dr. H. 0. Wooten^ of Alabama says that he has " never seen a 
decided case of tetanus nascentium that did not prove fatal. .... and that 
it is very generally deemed useless to call in medical aid after the initiatorv 
symptoms are well declared." Mr. Maxwell," speaking in reference to the 
West Indies, says : " From observations which I have made for a series of 
years, .... I found that the depopulating influence of trismus nascentium 
was not less than 25 per cent. It scarcely has a parallel within the bills of 
mortality." Dr. D. B. Nailer^ says : '• About two-thirds of the deaths among 
the negro children are from this disease, and so uniformly fatal is it that a 
physician is never sent for." 

Yet death does not always result : eight of the forty cases in my collection 
recovered ; but a correct opinion cannot be formed from this of the actual 
ratio of favorable to unfavorable cases, since favorable cases are much more 
likely to be published. In the history of these 8 cases two interesting facts 
are noticed, which when present may serve as a ground for hope of a success- 
ful termination. These were, the age at which the disease began and the 
fluctuation of the symptoms. With two exceptions, the infants who recov- 
ered were about a week old when the initiatory symptoms appeared, and there 
were fluctuations in the gravity of the symptoms ; whereas fatal cases ordi- 
narily grow progressively worse. Yet in favorable cases the symptoms are 
never so severe as they become in a few hours in those who succumb. 

Duration in Fatal Cases. — Of 18 cases observed by Finckh in the 
Stuttgart Hospital, 15 died in two days, 2 in five days, and 1 in seven days. 
During the epidemic in the Stockholm hospitals in 1834, where 42 cases were 
treated, the disease seldom lasted more than two days. Romberg says : " It 
generally lasts from two to four days, but its duration is at times limited at 
from eight to twenty-four hours, and occasionally, though rarely, it extends 
from five to nine days." 

In 81 fatal cases in my collection, in which the duration is mentioned — 

1 lived 3 hours. 

11 others lived 1 dav or less. 

12 lived 2 days. 

4 lived 3 days. 

3 lived 4 days. 

Both Underwood, who published a treatise on diseases of children in 
1789, and Dr. Elsasser at a more recent date, recorded fatal cases which were 
unusually protracted. The one described by Underwood was treated in the 
British Lying-in Hospital, and, although all the others treated in this institu- 
tion died by the third day, this lived six weeks ; but it is suggested by the 
author that death was due in part to some other afl"ection. The child treated 
by Elsasser lived thirty-one days. 

Duration in Favorable Cases. — In the 8 favorable cases in my col- 
lection the duration of the disease, reckoned from the time when the infant 
ceased nursing till it began again, was as follows : In 1 case, two days ; in 
1, a few days ; in 1, fourteen days; in 2, fifteen days; in 1^ twenty-eight 
days; in 1, twenty-one days; and in the remaining case, about five weeks. 

Diagnosis. — To one who has seen this disease in the new-born or is 
familiar with its symptoms diagnosis is easy. The symptoms which possess 
diagnostic value are more manifest and reliable than in most other infantile 
maladies. Permanent rigidity of the voluntary muscles, with temporary 
exacerbations, such as have been described above, which are induced by any 

' N 0. Med. Jour., May, 1846. 

■•^ Jamaica Phys. Jour., copied into the London Lancet, April 11, 1835. 

^ N 0. Med.' Jour., Nov., 1846. 



TREATMENT. 173 

cause which disturbs the infant — as attempts to open the mouth or eyelidsr — 
is pathognomonic. 

Preventive Treatment. — While tetanus neonatorum, if fully developed, 
is ordinarily fatal in spite of any remedial measures heretofore used, there is 
no doubt of the efficacy and value of preventive measures when properly 
employed. This was shown by the great reduction in mortality in the Dub- 
lin Lying-in Hospital through the thorough ventilation introduced by Dr. 
Clarke. Dr. Meriwether^ of Montgomery, Ala., says: "When the disease 
appears endemically on a plantation it may be arrested by having the negro 
houses whitewashed with lime inside and out ; by raising the floors above the 
ground; by removing all filth from under and about the houses; by par- 
ticular attention to cleanliness in the bedding and clothing of the mother ; 
and in the dressing of the child, so as to prevent any of the matter from the 
umbilicus lying long in contact with the skin. Many physicians, especially 
in the Southern States, speak confidently of care in dressing the cord and 
attention to the umbilicus as a means of prevention. Grafton'- says that he 
has •• never known the disease to occur in any child whose navel had the tur- 
pentine dressing." He uses turpentine as follows: '• At the first time a few 
drops of undiluted turpentine are applied immediately to the umbilicus around 
the cord, and it is anointed at every succeeding dressing, the turpentine being 
diluted one-half or two-thirds with olive oil, lard, or fresh butter." This use 
of turpentine has also been recommended by other practitioners in warm 
regions. 

Dr. John Furlonge ^ of St. John's, Antigua, believes that no case would 
occur with the following treatment : " The cord, when divided, should be 
wrapped in clean linen. Every night for two weeks one or two drops of 
tinct. opii and spts. vini, equal parts, should be given, and castor oil, with a 
little magnesia, every morning. The child must be washed in tepid water 
every morning and the funis dressed." If this treatment be attended by the 
success which is claimed for it by Dr. Furlonge, so great care in dressing the 
cord is certainly well repaid in localities, as at Antigua, where a large pro- 
portion of the infants die of tetanus. 

Some experienced observers go so far as to assert that it is possible to 
ward off tetanus neonatorum after the occurrence of premonitory symptoms. 
Dr. Dowell * says : " Some with slight twitchings of the muscles have recov- 
ered without any trouble by being put into a mustard-bath, washed clean, and 
put in a clean and well-ventilated cabin." 

Treatment. — In considering the eifect of medicinal agents which have 
been employed in the treatment of infantile tetanus, the great difficulty which 
the child experiences in swallowing should be borne in mind. Without care 
a considerable part of the dose is lost by the spasm of the muscles of degluti- 
tion, which ordinarily occurs when the spoon is placed in the mouth, so that, 
unless special attention be given to this matter, it is uncertain whether the 
prescribed dose is fully administered. 

The treatment employed by difi'erent physicians has been very diverse. 
Antiphlogistic remedies were prescribed by Finckh, but every case so treated 
was fatal. He states that whenever blood was abstracted, even in small quan- 
tities, the symptoms were aggravated. The same result has followed depletory 
measures in the practice of other physicians. 

The internal remedies which have been most frequently prescribed are 
opiates and antispasmodics. Furlonge in a favorable case gave laudanum in 

^ Amer. Jour, of Med. Sei., April, 1854. 
2 .V. 0. Med. and Surg. Jour., July, 1858. 
^ Edin. Med. and Surg. Jour., Jan., 1830. 
* Amer. Jour, of the Med. Sci., January, 1863. 



174 TETANUS NEONATORUM. 

doses of one drop every three hours ahernately with two grains of Dover's 
powder. Woodworth also gave one-drop doses of laudanum ; Eberle, one- 
sixth of a drop hotirly. The opiate has generally been given in combination 
with an antispasmodic. The Dover's powder given every three hours by 
Furlonge was combined with five grains of sulphate of zinc. The hourly 
doses of laudanum by Eberle were combined with six drops of tincture of 
asafoetida. 

When anaesthetics began to be employed in the treatment of diseases, it 
was believed that they would be especially useful in cases of tetanus. Accord- 
ingly, chloroform has been used in tetanus in the infant, with the effect of 
controlling the spasm during the time of its use, but without curing the dis- 
ease. In Case 7 in our first table it was employed several times, but appar- 
ently without delaying the fatal result. The editor of the New Orleans 
Medical and Surgical Journal states, in the May issue of that periodical for 
1853, that he has used chloroform in tetanus neonatorum, with the effect, he 
believes, of prolonging life. Anaesthetics certainly relieve the suffering of 
the infant, and on this account, even if they do not prolong life, their judi- 
cious employment seems proper. 

The remedy which, in my opinion, is far preferable to all others is hydrate 
of chloral. Since the introduction of this agent into therapeutics it has been 
employed by several physicians in the treatment of this disease with so good 
a result that it will probably supersede all other medicines for this purpose. 
Dr. Widerhofer ' of Vienna states that he has saved six out of ten or twelve 
by the use of chloral. He prescribes it in doses of one to two grains by the 
mouth, or, if there be great difficulty in swallowing, two or four grains by the 
rectum. Dr. F. Auchenthales'^ relates a casein which he gave even six- 
grain doses, and in nine days the disease had entirely disappeared. I have 
recently employed hydrate of chloral in a case of tetanus, giving it in half- 
grain doses every two hours, except when there was profound sleep. The 
disease was fully developed and the symptoms severe when I was called. I 
did not believe that the infant with the old remedies would live more than 
two days, but by the chloral life was prolonged nearly one week. Moreover, 
by the use of chloral the suffering of the infant is greatly diminished. The 
frequent inhalation of sulphuric ether also aids materially in controlling the 
spasms. 

The administration of alcoholic stimulants is required at short intervals 
on account of the rapid emaciation and great prostration. 

Local treatment directed to the umbilicus in those cases in which there 
is evidence of inflammation of the umbilicus or umbilical vessels should not 
be neglected. The application of an emollient poultice to the umbilicus has 
been followed by apparent improvement, if we may believe the statement of 
some physicians who have made use of this treatment. Dr. Meriwether of 
Alabama says if there be no improvement from the medicine which he orders 
he applies a blister, larger than a dollar, to the umbilicus, and with this treat- 
ment the child generally improves — a remarkable statement, since so few 
improve at all. 

A warm foot-bath, repeated at intervals of a few hours, and stimulating, 
embrocations along the spine, are proper adjuvants to the treatment. 

Sclerema Neonatorum. 

This is a rare disease, and most of the cases which have been observed 
have occurred in foundling asylums or maternity wards. It is characterized 
by induration or rigidity of the skin and subcutaneous tissue over a greater or 

^ London Lancet, March 18, 1871. ^Jahr.f. Kinderheil, N. S., iv. 



SCLEREMA NEONATORUM. 175 

less extent of the system. The sensation communicated to the finger pressed 
upon the affected surface is not unlike that produced by the cadaver. Those 
having the disease are feeble, poorly nourished, and a considerable proportion 
are prematurely born. Their temperature is below normal. 

Sclerema of the newly-born was first described by Underwood in the 
eighteenth century, and following him, in 1781, Andry applied this term to 
cedema occurring in the first days after birth, and which should not be con- 
founded with sclerema. Sclerema neonatorum occurs in emaciated or atro- 
phic infants, but the skin over the affected part, instead of lying in wrinkles, 
or folds, as is usual in a state of great emaciation or atrophy, becomes 
smooth and is firmly adherent to the subjacent parts, from which it cannot 
be raised. The induration usually first appears in the lower extremities, and 
it passes upward along the hips and lumbar region, and it may occur not only 
upon the trunk and upper extremities, but even upon the face. The limbs 
are extended and immobile, and the soft parts, firm and resisting, do not pit 
on pressure. The skin has a dusky-yellow color and is perhaps slightly 
cyanotic. The respiration is feeble and slow. The rigidity when extensive 
resembles that in tetanus. Nursing from the breast is imperfectly performed, 
and when the muscles of the face and lips are involved is impossible. The 
causes of sclerema appear to be prematurity, atrophy or poor nutrition, and 
great heart failure. 

This disease, so long as the patient is able to take nutriment, may con- 
tinue for weeks before the fatal ending, with a constant abnormally low tem- 
perature. 

Parrot made post-mortem examinations, and found hardening and atrophy 
of the skin and rete Malpighii, the cells pertaining to which being indistinct 
and forming a firm mass. In the adipose tissue underlying the skin the fat 
had disappeared to a considerable degree, the fat-cells being atrophied, but 
having distinct nuclei. The fibres of the connective tissue w^ere apparently- 
increased in number and thickness. The blood-vessels, particularly in the 
papillae, were shrunken or narrowed to such an extent that their lumina were 
not visible. Henoch made a post-mortem examination of the brain and spi- 
nal cord in two cases which had lain for weeks in his ward in a rigid state,, 
and found them normal. 

A clear idea of the symptoms and anatomical characters of sclerema caii 
be obtained by the narration of a typical case that occurred in the New York 
Foundling Asylum. Dr. W. P. Northrup, the curator, gave a full and 
graphic description of this case at the first session of the American Paediatric 
Society : The patient, a female, was brought to the asylum as a foundling at 
the age of five days. It was jaundiced, had sprue, and a rectal temperature 
of 96^° F. The efforts to increase its temperature were unavailing, and two 
days later it was carefully examined. Its face was cold and rigid, and the 
coldness and rigidity had extended over not only the features, but the scalp, 
shoulders, arms, hands, hips, thighs, legs, and feet. The extremities were so 
stiff that pressure upon them or attempts to move them communicated the 
sensation of a cadaver or half-frozen tissue. Its eyes were closed ; its sur- 
face had a dirty, yellowish-brown color. When handled it uttered a feeble 
whimpering cry, but was otherwise motionless and quiet ; no pulse ; rectal 
temperature below the lowest figure on the thermometer ; respiration feeble 
and shallow. Death occurred two days later, at the age of nine days. 

At the autopsy the sclerema was found to be less in the abdominal walls 
than elsewhere. On incising the hardened tissues no blood or serum escaped 
from the cut surface. The lungs had been fully inflated, no collapse being 
present, and they contained dark hemorrhagic points or spots. Nothing 
unusual was observed in the skull, brain, heart, and great vessels, the 



176 TETANUS NEONATORUM. 

stomacli, intestines, liver, and kidneys, except the urates in the tubuli 
uriniferae. The hemorrhagic extravasations in the lungs were found to con- 
sist of fresh blood in the alveoli and connective tissue. Dr. Northrup made 
microscopic examinations of the skin and subcutaneous tissues, and found 
that they took injections well, showing a normal vascular network. The 
microscopic slides have been examined by expert microscopists and derma- 
tologists, and they can discover nothing abnormal that throws light on the 
cause or pathology of the sclerema. 

Sclerema bears considerable resemblance to oedema of the new-born. In 
oedema the temperature is low and the oedematous tissues may present con- 
siderable firmness, but the surface usually pits on pressure, unlike that in 
sclerema. Of the different opinions expressed by observers in reference to 
the cause and pathology of sclerema, that expressed by Ludwig Langer in 
1881 ( Wiener SitzungshericJif^ 1881) is the most plausible. It is as follows : 
In the adult oleic acid is the chief constituent of the adipose tissue, but in 
the newly-born the fat contains a large proportion of palmatin and stearin, 
which solidify when the heat of the body undergoes a moderate reduction 
below the normal. 

Infants having sclerema after lingering for days or weeks die in a state of 
extreme weakness. I am not aware that recovery has occurred in any case 
of genuine sclerema of the new-born. Still, it is proper to increase the tem- 
perature by warm applications to the body and limbs and to endeavor to 
improve the nutrition in every possible way. Perhaps a more abundant 
breast-milk or breast-milk of a better quality can be obtained, and a few 
drops of Tokay or other good wine or of brandy may be given every sec- 
ond hour. 

CEdema Neonatorum. 

In this disease thickening of the integument occurs and the subcutaneous 
connective tissue is infiltrated with serum. The oedema in most cases is at 
first in the legs, from which it extends along the thighs to the genitals. It 
may extend over the trunk, upper extremities, and cheeks, but in some cases 
it appears only in the hands and feet, producing tumefaction of the palms of 
the one and soles of the other. If the amount of serous infiltration be great, 
the tissues may be firm and resisting, communicating to the touch a sensation 
similar to that in sclerema ; but when the infiltration is less in degree the tis- 
sues are soft and doughy. The skin has a dusky or yellowish color, and 
sometimes, when much distended, it has a shiny appearance. In cases of 
great oedema the movement of the affected part is diminished, but not to the 
same extent as in sclerema. As in sclerema, the temperature is below the 
normal. 

In fatal cases the adipose tissue is found of a brownish, yellowish, or 
reddish-yellow color, from which a yellowish serum exudes. (Edema of the 
newly-born does not appear to result from the same cause in all instances. 
Occurring in feeble, ill-nourished infants, it apparently results, in most in- 
stances, from extreme heart-weakness. The feeble circulation leads to venous 
congestion and consequent serous transudation. Pulmonary atelectasis, occur- 
ring as it usually does in ill-nourished and feeble infants, is also an occasional 
factor in producing venous stasis and transudation of serum. Elsasser has 
shown that occasionally in the newly-born the oedema results from nephritis, 
as it frequently does in the adult. Henoch relates the case of an infant of 
four weeks who had '• marked oedema of face and limbs," with serous efi^u- 
sion in the pleural, pericardial, and peritoneal cavities, and compression of the 
left lower lobe, resulting from parenchymatous nephritis. Another occasional 



PEMPHIGUS NEOXATORUM. 177 

cause of the oedema is erysipelas. This cause is revealed by the dark -red 
color of the skin characteristic of erysipelatous inflammation. 

Recently Prof. Dumas in an elaborate paper on oedema of the new-born 
arrives at the following conclusions: ''1. (Edema of the new-born is only 
one of the symptoms of a phlegmasia alba dolens which is developed during 
the first days after birth. 2. Its causes are of the same nature as in the 
adult, and may foe divided into predisposing and determining varieties. Among 
the latter, the principal one consists in the incomplete establishment of res- 
piration or in the pathological or other causes which this function encounters, 
o. The symptoms of phlegmasia in the new-born are the same as in the adult, 
excepting certain modifications with respect to the special phj'siology of the 
first days following birth. 4. The pathological anatomy is also about the 
same, but the venous thrombosis in the new-born is more frerjuenily located 
in the inferior vena cava than it is in the same disease in the adult." It does 
not seem improbable that Prof. Dumas's explanation is applicable to a consid- 
erable proportion of cases, the formation of clots in the veins producing such 
obstruction and venous congestion that serum transudes as a consequence. 
Dumas recommends, in order to prevent this disease, •' suitable care to effect 
respiration in the new-born at the moment of birth, and not too hasty liga- 
tion of the cord."' 

(Edema, like sclerema, is ordinarily fatal, but occasionally, as when it 
results from erysipelas, recovery is possible. The treatment should be largely 
hygienic and dietetic. An abundant supply of good breast-milk should be 
obtained, or if this be impossible peptonized cow's milk. As in sclerema, 
artificial warmth and moderate alcoholic stimulation are required. 

Pemphigus Neonatorum. 

Pemphigus occurs in two distinct forms in the newly-born, which may be 
properly designated pemphigus simplex and pemphigus cachecticus. 

Pemphig'us Simplex commonly occlirs between the ages of two and 
twelve days. The vesicles, which vary in size from that of a pea to a hazel- 
nut, appear in some cases nearly simultaneously, but in other instances in 
successive crops. When fully developed, they ordinarily have a tran.sparent 
yellowish color, and they may appear upon almost any part of the surface 
except the palms of the hands and soles of the feet. When the eruption is 
nearly general upon the surface, as it occasionally is, one or two blebs may 
even appear upon these parts, but as a rule in pemphigus simplex the palms 
of the hands and soles of the feet are not affected. 

In investigating the causes of this form of pemphigus we are struck with 
the fact that in a considerable proportion of the recorded cases those affected 
with it appear to be otherwise in perfect health. Occasionally in maternity 
hospitals it occurs as an epidemic. Thus. Ahlfeld observed twenty-five cases 
during two months in an institution in Leipzig. The mothers of these infants 
were apparently healthy, and the pemphigus commenced in all between the 
second and fourteenth days after birth. The palmar surfaces of the hands 
and plantar surfaces of the feet were not affected in any of these cases, though 
vesicles appeared on the fingers in some of them. Ahlfeld, from these 
observations, believed that the disease was infectious or of a miasmatic nature. 
Koch states that thirty-one cases occurred in the practice of a certain mid- 
wife, while in the practice of other midwives no case occurred. Weyl of 
Berlin, aware of facts like the above, states that the disease is undoubtedly 
contagious. Bohn, on the other hand, regards cutaneous irritants as a cause, 
and he states that the repeated occurrence of pemphigus in the practice of 
a certain midwife was traced to the fact that she habitually used water too 
12 



178 TETANUS NEONATORUM. 

hot in bathing the infants. But there is now a sufficient number of observa- 
tions to render highly probable, if they do not demonstrate, the contagious 
nature of pemphigus in certain cases. Koeser always found micrococci in 
the serum of the vesicles. Gibier found chain bacteria, single bacteria, and 
also bacteria in zoogloea in the vesicles. Scharlau met the disease in different 
members of a family, and succeeded in inoculating himself from the vesicular 
contents. We may conclude, therefore, that pemphigus of the newly-born 
is probably in certain cases microbic and inoculable, though the microbe 
which causes the disease has not been fully identified. But in some instances 
it is not improbable that the disease is produced by causes not microbic, as 
from cutaneous irritants. Further investigations in regard to the etiology 
of pemphigus simplex are required before positive statements can be made. 

Pemphigus simplex is usually attended by little constitutional disturb- 
ance, but sometimes, it is said, a slight fever attends the eruption of the 
vesicles. The skin adjacent to the vesicles may have the normal or a slightly 
congested or vascular appearance. The vesicular contents escape in a few 
days by rupture of the vesicle, or disappear by absorption, and the detached 
cuticle forms a thin scale which is soon thrown off, and in a few days replaced 
by a new growth of cuticle. 

Pemphigus Cachecticus. — This form of pemphigus occurs in infants 
who have a profound cachexia, and this cachexia is in a large proportion of 
cases due to inherited syphilis. Unlike pemphigus simplex, it attacks by 
preference the palms of the hands and soles of the feet. It also occurs upon 
thin portions of the skin, as the groin, axilla, and neck. The surface upon 
which the vesicles are situated presents a reddish or livid appearance, and the 
vesicles are only partially filled. The exuded liquid is not so clear as in 
pemphigus simplex, and it is often turbid or even bloody. The vesicles or 
remains of vesicles are sometimes observed at birth, and are then believed to 
have a syphilitic origin. When the cause is syphilis other manifestations of 
this disease may be also present. 

Pemphigus cachecticus may be prolonged several weeks, if the patient live, 
by the occurrence of new vesicles. It is important, as regards the selection 
of remedies, to bear in mind the fact that the profound dyscrasia which 
underlies and gives rise to an attack of pemphigus cachecticus may occur 
from other causes than syphilis, as perhaps struma. The evils which attend 
a family subjected to a life of poverty in a great city, as overwork, scanty 
and poor diet, overcrowding, and foul air, may be the cause of the dyscrasia 
in the infant born under such circumstances, even when the parents are 
actuated by the best motives and endeavor to lead a correct life. 

Anatomy. — The vesicles occur in the epidermis between the layers of 
the stratum granulosum and stratum lucidum (Weyl). The contents of the 
vesicles consist largely of serum, but sometimes also of other substances, as 
pus-cells, epithelial cells, etc. 

Treatment. — This is simple, consisting of cleanliness, the use of abun- 
dant pure breast-milk, and frequent dusting the surface with a powder consist- 
ing of bismuth and lycopodiura. In the cachectic form of pemphigus, espe- 
cially if the vesicles have an unhealthy appearance, they should be broken, 
and their surface may be dusted with a powder of one part of iodoform and 
ten of bismuth. In syphilitic cases Henoch recommends the addition of 1 
gramme (15 grains) of corrosive sublimate to the bath employed. The use 
of a few drops of Tokay wine or other alcoholic stimulant at each nursing is. 
also required in the cachectic cases. 



PART III. 

CONSTITUTIONAL DISEASES. 



SECTION I. 

DIATHETIC DISEASES, 



CHAPTER I. 

RACHITIS. 

Rachitis, or rickets, is regarded as a constitutional disease, though the 
most prominent symptoms and lesions which characterize it pertain chiefly to 
the osseous system. It occurs in the first years of life, and therefore during 
the period of most active growth of the skeleton. It is manifested by an 
abnormal nutrition and changed physiological action of the bone-producing 
tissues — namely, the epiphyseal cartilage and the periosteum — and by the 
arrest, more or less complete, of the deposition of lime-salts in these 
tissues. 

Frequency of Rachitis. 

Rachitis is a common result of faulty diet and of antihygienic conditions, 
and is therefore frequent among the poor of cities, and especially in families 
who dwell in crowded tenement-houses. It has heretofore been prevalent in 
the city infantile asylums, but of late years, as regards at least the city of 
New York, it is much less common, in consequence of the greater attention 
now given to sanitary requirements in the management of these institutions. 
Mild cases of rickets are often overlooked, since physicians may not be sum- 
moned to attend them, while, even if they be summoned, many who have not 
given particular attention to this disease are apt to err in diagnosis and to 
refer the symptoms to some other than the true cause. Commencing grad- 
ually and insidiously, rachitis not infrequently continues for months, even in 
its typical form, before a correct diagnosis is made. In the absence of deform- 
ity, which is a late symptom, the fretfulness. tenderness of surface, and per- 
spirations receive a wrong explanation. Practitioners who have heretofore 
given little attention to this malady, and who believe it to be rare, if they 

179 



180 RACHITIS. 

are instructed in reference to its characteristic si^ns, and look for them in 
their visits among the city poor, are surprised at the number of cases which 
they meet. A few years since in the New York Infant Asylum my atten- 
tion was directed to a rachitic child whose head had so changed from the 
normal shape that the nurses, as well as the physician, had remarked the dif- 
ference. Prompted by the occurrence of this case, which had gradually 
developed under my eyes, I made a careful examination of all the infants, 
and discovered, what I had not previously suspected, that about one in nine 
had become rachitic. In most of the infants the disease was mild, but with 
symptoms so characteristic that it was readily recognized. By effecting cer- 
tain improvements in the diet, among which was the daily allowance of beef 
tea to the older infants, rachitis, unless of a mild type, has since been rare in 
this institution. 

The late Dr. John 8. Parry of Philadelphia stated that at least 28 per 
cent, of all the children between the ages of one month and five years who 
came under his observation in the Philadelphia Hospital during the three 
years preceding the publication of his paper, in 1872, were rachitic. This 
is certainly a larger proportion of those who present indubitably rachitic 
symptoms than occurs in any of the three New York institutions for chil- 
dren with which I have an official connection. In the New York Foundling 
Asylum, with its sixteen hundred inmates, and in the Bureau for the Belief 
of the Out-door Poor, where over eight thousand children are annually 
treated, rachitis is certainly less frequent than is indicated by the statistics 
of Dr. Parry. In Europe, from the testimony of many observers, both con- 
tinental and British, rickets is very common among the families who seek 
medical advice in the institutions of charity. Bitter von Bittershain finds 
that 39 per cent, of all the children who are brought to the Prague Medical 
" Poliklinik " are rachitic, and Prof. Henoch states that the proportion is 
equally large in the families of Berlin who are in similar reduced circum- 
stances. According to Dr. Gee, whose statement was, however, made as far 
back as 1867-68, of the patients under the age of two years in the London 
Hospital for Sick Children, 80.3 per cent, are rachitic. Both Dr. Hiller and 
Sir William Jenner not only allude to the frequency of rachitis, but state 
that it is the cause of many deaths in London families. Chalybseus states 
that of nearly three thousand children in Dresden brought to him for vac- 
cination, 8.4 per cent, exhibited signs of rachitis. In an interesting com- 
munication read at the meeting of the Ninth International Medical Congress 
in 1887, Dr. Moncorvo of Brazil stated that 45 per cent, of the sick children 
treated by him in Bio Janeiro had rachitis. In New York City rachitis is 
very common in the families of Italian immigrants. According to my 
observations in the Bureau for the Belief of the Out-door Poor, a majority 
of the most pronounced cases, attended with great enlargement of the joints 
and marked curvatures, come from the Italian tenement-houses. 

But rachitis does not occur exclusively among the poor. Children of 
well-to-do families are also liable to it, provided that the conditions soon to 
be enumerated are present. Ignorance or disregard of the hygienic require- 
ments of young children, and especially the use of improper diet, leads to 
the development of rachitis in wealthy as well as in destitute families. Merei, 
in his treatise on the Dhorder^ of Infantile Development (London, 1855), states 
that in Manchester, where his observations were made, one child in every 
five in families in comfortable circumstances present rachitic symptoms : and 
he believes that this cannot be much above the real proportion in '' the whole 
of the wealthy classes." 

Bachitis, in its milder form, is not uncommon in affluent families in this 
country, the cause of the delayed dentition, the fretfulness, and perspiration 



AGE AT WHICH RACHITIS OCCURS. 



181 



not being suspected in many instances, as I have had opportunities to observe. 
Often family physicians are not consulted in reference to such symptoms, and 
when they are called in so little attention has rachitis received on the part of 
many practitioners that they are very apt to overlook the true pathological 
state which is present. Still, admitting the fact that many cases are not 
diagnosticated, I repeat that, though rachitis is not uncommon on this side 
of the Atlantic, its percentage of frequency falls below that observed in 
European cities — a fact which may be due to less crowding in their domiciles 
and to a more liberal and better supply of food among the families of the 
poor in this country. 



Fig. 10. 



Age at which Rachitis Occurs. 

Rachitis is, with few exceptions, a disease of infancy, commencing prior 
to the age of two and a half years. Now and then it. or a state closely 
resembling it, occurs in the foetus, causing deformities 
such as are present in typical cases. In the Kinder- 
spital 3Iuseum at Prague is a specimen showing this, 
and described by Ritter, Hink and Winkler also 
describe such cases, and Yirchow alludes to a specimen 
in the Wurzburg Museum which exhibits such deform- 
ities as characterize rachitis. Bednar even regards 
foetal rachitis as not uncommon (Hillier, Parry). In 
the Wood Museum of Bellevue Hospital is a skeleton 
which is probably similar to those in the Prague and 
Wurzburg Museums. It shows in a striking manner 
the deformities of this congenital disease. The case 
occurred in my practice, and the dissection was made 
by Prof. Francis Delafield. The infant, born at term, 
died a few hours after birth from atelectasis, appa- 
rently produced by the contracted state of the thoracic 
walls. The parents were hard-working English people 
whose mode of life and surroundings were such as are 
known to conduce to rachitis. They were free from 
syphilitic taint. The accompanying woodcut (Fig. 10) 
represents this skeleton. 

The following remarkable case of supposed foetal 
rachitis was related to me by Heitzmann. whose inter- 
esting experiments will be presently detailed : 




Skeleton of a Rachitic 
Infant which died a few 
hours after birth. 



Case 1. — A woman who had frequently inhaled the vapor of lactic acid each 
day for many months, as she was employed to feed animals with this agent, gave 
birth to an infant at term which died immediately after it Avas born. It exhib- 
ited the signs of congenital rachitis in a high degree. The skull-bones were 
completely absent; in the cartilages of the bones of the extremities and in those 
of the ribs there 'were scanty depositions of lime-salts. The death of the child 
was evidently due to the absence of the skull-bones, inasmuch as the pressure 
of the womb during delivery had caused cerebral hemorrhage. All the organs 
of the chest and abdomen were found in full development and healthy. 

We will see hereafter that the theory which attributes rachitis, in certain 
instances, to a chemical irritant is substantiated by experiment, and that it 
has already been shown that two such agents, phosphorus and lactic acid, 
may cause this disease. Now, as the irritating action of phosphorus on the 
osseous system occurs when it is inhaled in the form of vapor as well as when 
received in the ingesta, so lactic acid, if the above case be rightly interpreted. 



182 RACHITIS. 

produces its special eflPect upon the bone-producing tissues when inhaled as 
decidedly as when received in the ingesta or generated in the system. These 
remarks seem necessary for an understanding of this unusual case, although 
they anticipate what will be said under the head of Etiology. In the New 
York Journal of Obstetrics for November, 1870, Prof. Abraham Jacobi also 
published the description of a case of congenital rachitic craniotabes. Whether 
or not we accept as genuine all the reported cases of foetal rachitis, there can 
be little doubt, from the number of observations already made and carefully 
recorded and from the opinion of high authorities like Virchow, that such 
cases do occur. 

Recently Schwarz examined five hundred newly-born infants in the obstet- 
ric clinic in Vienna, and he states that only 19.4 per cent, were entirely free 
from signs of rachitis. This remarkable statement we hesitate to accept, 
thinking that there may have been some error in the observation.^ 

Enlargement of the costochondral articulations, known as the " rachitic 
rosary," which is one of the earliest and most reliable signs of rickets, has 
been observed, though rarely, in infants only a few weeks old. Dr. Parry 
saw it as early as the sixth week after birth ,'^ and Dr. Gee at the third or 
fourth week.^ This should not, however, be regarded as a sign of rachitis, 
unless the enlargement be so great that it can be readily appreciated by 
examination through the integument or by sight, for in young children, with 
the bones in the process of normal development, these joints usually have a 
diameter a little larger than that of the ribs. Rachitis, with few exceptions, 
begins within the first eighteen months of life. Though first detected and 
diagnosticated at a later date, it will ordinarily be ascertained, on inquiry, 
that its symptoms had an earlier beginning. Still, according to certain 
observers, it may have a considerably later commencement. Glisson, Portal, 
and Tripier state that they have seen it commence in children who were well 
on toward the age of puberty. Sir William Jenner states that he has seen 
children of seven and eight years who were only beginning to suffer from 
rachitis.* 

The following are the aggregate statistics of Bruennische, Von liittershain, 
and Ritsche, relating to the age at which rachitis occurs : 

No. of 

During the first half year 99 

*' second half of first vear 259 

" vear . . . / 342 

" third year 134 

" fourth vear 31 

" fifth year . . . _ 17 

Between the fifth and ninth years 21 

Aggregate • ' 903 



Causes of Rachitis. 

Inheritance. — In some infants there is an undoubted hereditary pre- 
disposition to rachitis. Feeble digestion and defective assimilation in the 
infant — which are, as we shall see, important factors in producing the rachitic 
state — are often traceable to disease or cachexia of one or both parents. The 
offspring of a tubercular, syphilitic, or otherwise enfeebled parent is more 
likely to become rachitic than those of healthy and robust ancestry ; and it 
appears that disease of the mother is more likely to entail a rachitic predis- 

^ Annual of Med. Scl, 1889. 

^ American. Journal of the Medical Sciences, January, 1872. 

3 St. Bartholomew's Hospital Reports, vol. iv. ^Lancet, December 11, 1880. 



CAUSES OF BACHITIS. 183 

position than that of the father. Among the parental causes may be men- 
tioned poverty, hardships, and defective nutrition of either parent, age of the 
father, and exhausting discharges of the mother, such as purulent, hemor- 
rhoidal, or uterine flaxes. 

Food. — Of the exciting causes, the most common is the use of food not 
sufficiently nutritive, or, if nutritious, not suited to the age and digestive 
powers of the child. Thin and poor breast-milk and artificial food of poor 
quality or not suitable for the stage of growth and development are common 
causes of rickets. Those children who have been prematurely weaned, and 
who have been given a food which is not a proper substitute for the natural 
aliment, and those too long wet-nursed and not allowed the additional nutri- 
ment which they require, are especially liable to this disease. Those whose 
digestive power is feeble from whatever cause are more liable to become rachitic 
than those who, in a state of robust health, have a hearty digestion. Hence 
we meet with rickets as a sequel of various protracted and exhausting 
maladies during infancy. 

It might be supposed, from the nature of rachitis, that the use of food 
deficient in phosphoric acid and lime is the common cause of rachitis ; but 
facts show that this is not the correct view of its etiology as it commonly 
occurs, although in its treatment these agents are of undoubted value. The 
disturbed and altered nutrition of the osteoplastic tissues — namely, of the 
epiphyseal cartilage and the periosteum — is the important factor in producing 
the rachitic bone disease, and this may occur although the ingesta contain a 
sufficient amount of phosphoric acid and lime. Deficiency of these substances 
probably tends to diminish the amount of lime-deposition, but it is not the 
essential element in the causation of the malady. This is to be found in the 
unhealthy condition and action of the cartilage and periosteum, or rather in 
the agencies, now partly ascertained, which produce the abnormal state and 
altered nutrition of these tissues. 

Cheadle believes that the chief cause of rachitis is bad feeding. Hand- 
fed infants, he says, are especially liable to it, particularly if their diet be 
farinaceous. W. H. Peters reports a case caused, he thinks, by feeding with 
undiluted cow's milk. The child, eight months old, was ordered milk and 
lime-water, equal parts, and in three months, the signs of rachitis had dis- 
appeared.^ 

The important fact has been ascertained by experiments on young animals 
that rachitis can be produced, as I have already stated, by at least two chem- 
ical agents, which may be admitted into the system in the ingesta, and which 
exert an especially irritating action on the osteoplastic tissues. Senator states, 
in Ziemssen's En a/ elapsed la, that " Wegner .... has recently brought experi- 
mental evidence to show that true rickets may be artificially produced by the 
continued administration of very minute doses of phosphorus, .... together 
with a simultaneous withdrawal of lime from the food." The fact being 
established that it is possible to produce rickets by certain deleterious prin- 
ciples in the ingesta opens an interesting field for experimental inquiry. 
Since improper feeding and indigestion are known to sustain a causative 
relation to rachitis, experiments have been made to ascertain whether some 
chemical agent, developed in the system during the digestive process or intro- 
duced with the food, may not cause rachitis as it ordinarily occurs in the 
infant. Among the foremost in that line of experiment has been Dr. Heitz- 
mann, a resident of Vienna when his observations were made, but now of 
New York. 

In young children acids, especially the lactic, are commonly produced, 
and often in large quantities, as the result of improper feeding, of indigestion, 

^ Annual of the Unicer. Med. ScL, 1889. 



184 RACHITIS. 

and of intestinal catarrh. The acidity of the infant's stools under such con- 
ditions of ill-health is well known. What more natural, then, than the sup- 
position or belief that this acid, thus generated, sustains the same causative 
relation to rickets as phosphorus in the experiments which have been made 
with that agent. But the acid which is produced so abundantly in disturbed 
states of the digestive apparatus in the infant, believed to be chiefly the 
lactic, must, in order to reach the bones and influence their nutrition, pass 
through the blood, which is always alkaline. This difficulty in the way of 
the theory that lactic acid is the irritating agent is removed by physiologists, 
who tell us that among the organic acids the existence of lactic acid in healthy 
blood is not entirely beyond doubt, but that it has been found in the latter 
under abnormal conditions.^ Lactic acid has also been found, after having 
made the circuit of the system, in the excretion from the kidneys. 

Heitzmann, in order to ascertain whether this acid sustained a causal 
relation to rickets, made a series of experiments which have passed into the 
literature of this disease, and he has kindly furnished me with their details, 
as follows : 

" Marchand, Ragsky, Lehman, Simon, and others have found free lactic 
acid in the urine of persons sufi"ering from rickets and osteomalacia. C. 
Schmidt discovered lactic acid in the liquid of malacic shaft-bones which 
were transformed into globular cysts. Encouraged by these chemical 
researches, I undertook a series of experiments on the action of lactic acid, 
administered both by the mouth and by subcutaneous injection, upon the 
bones of living animals ; which experiments were begun in April, 1872, and 
continued until the end of October, 1873. The experiments were made upon 
five dogs, seven cats, two rabbits, and one squirrel. On dogs and cats under 
one year of age the lactic acid, given either by mouth or injection, in com- 
bination with restricted administration of calcareous food, produced swelling 
of the epiphyses of the shaft-bones and the anterior ends of the ribs at their 
attachments to the costal cartilages. This result was plain in the second 
week after the beginning of the lactic-acid treatment. Up to the fourth and 
fifth weeks the swelling of the epiphyses and of the ends of the ribs kept 
increasing, and then was accompanied by curvatures of the bones of the 
extremities. As accompanying symptoms I noticed catarrhal inflammation of 
the conjunctiva, of the mucosa of the bronchi, the stomach, and the intestines, 
with emaciation and convulsive movements of the extremities. The micro- 
scopic examination of the epiphyses gave an image fully identical with that of 
the epiphyses of rickety children. Upon continuing the administration of the 
lactic acid, the swelling of the epiphyses of the shaft bones gradually increased, 
and so did the curvatures of the same bones. After four or five months of 
lactic-acid treatment, under often-repeated catarrhal inflammations of the 
above-named mucous layers, the shaft-bones became soft to such a degree 
that they could be bent like the branches of a willow tree. After from four 
to eleven months of the same treatment the microscopic examination of the 
bones gave a result corresponding with that obtained from the bones of 
women who have died with osteomalacia. 

" On the three herbivorous animals no swelling of the epiphyses was 
noticeable. One rabbit died three months and the other five months after 
the commencement of administration of the lactic acid, but with symptoms 
of inanition. No marked evidences of rachitis or malacia were traceable in 
the bones of these animals. The squirrel, on the contrary, which died after 
thirteen months of treatment with lactic acid, gave all the features of osteo- 
malacia. 

" Miy experiments give the result that hy continuous administration of lactic 

^ Heinrich Frey of Zurich. 



CAUSES OF RACHITIS. 185 

acid, at first rickets, and afterward osteomalacia, can be artificialJij produced in 
flesh-eaters ; while in herhivorous animals osteomalacia sets in icithout preceding 
symptoms of rickets. Through these experiments I have proved the identity 
in nature of these two diseases, the diflf'erences in their course being due to 
the difference in the age at which the solution of the lime-salts is established. 
.... Rickets can be produced on dogs and cats only under the age of ten 
or twelve months. Mr. Hess fed with lactic acid a dog of the age of one and 
a half years, and failed to produce rickets. This result is in full agreement 
with my experiments. I maintain that lactic acid, though not free in the 
blood, if in contact with the tissues producing bone or with fully-developed 
bone, owing to its great affinity- for lime either prevents the formation of 
bone (rickets) or dissolves bone already made (osteomalacia)."' 

On the other hand, rachitis sometimes occurs in infants who present no 
history of indigestion or of intestinal catarrh, and in whom there is no ground 
for the belief that lactic or any other acid is produced in undue or injurious 
quantity. In a considerable proportion of such cases inquiry elicits the fact 
of antihygienic conditions, but there is no evidence of imperfect digestion or 
of gastro-intestinal catarrh, such as produces lactic acid. In the cases occur- 
ring in the New York Infant Asylum, alluded to above, some of the children 
had manifest gastro-intestinal derangement ; but others, who were wet-nursed, 
gave no evidence of faulty digestion, though the nutriment which they 
received was probably insufficient ; for, as already stated, by providing a 
more liberal diet, by allowing among other articles the juice of meat, rachitis 
became much less frequent, and is seldom observed at present among the 
infants of that institution, unless in a very mild form. 

Virchow and others have suggested that the prime factor in causing 
rachitis is the use of a diet that is deficient in calcareous salts, and we have 
seen that in the interesting experiments of Dr. Heitzmann the administra- 
tion of calcareous food to the animals was restricted. vStill, as Xiemeyer has 
well said, deprivation or restricted use of the chalky salts cannot possibly 
cause the most important histological change in rachitis — nameh', the prolif- 
eration of the epiphyseal cartilages and periosteum — and we must look for 
some other factor in the causation. 

Pathology furnishes many examples of chronic disease attended by pro- 
liferation of tissue, the causes of which are not uniform. Cirrhosis, with its 
proliferation of hepatic connective tissue, which, as we shall see, presents a 
similitude in some respects to rachitis, is sometimes undoubtedly produced 
by the irritating action of a chemical agent — to wit, alcohol ; but all phy- 
sicians know that there are many cirrhotic patients who refrain entirely from 
the use of alcohol in any form. In like manner, it seems to me that if we 
admit, as we must in the light of experiments, that certain chemical agents, 
notably phosphorus and lactic acid, introduced into the system or produced 
in it, cause rachitis by their irritating action, there are other t^'pical cases in 
which there is no reason to suspect the operation of such agents. We must 
therefore remain in the belief that rachitis, like many other pathological pro- 
cesses, does not result from a fixed and uniform cause, but from conditions 
which vary to a certain extent in different patients. Kassowitz believes that 
the osseous changes which occur in rachitis result from inflammation, which 
occurs from different causes. Comley believes that the cause of rachitis is a 
chemical change in the blood which occurs from digestive disorders. Cheadle 
believes that all other causes are subsidiary to bad feeding. Bottle-fed infants, 
especially those whose diet is mainly farinaceous, he says, are especially liable 
to rachitis.^ Grallois, Fournier, and Broca regard rickets as '' the expression 
of a constitutional degeneracy, of which the causes are multiple.'' The 
^ London Lancet. August, 1888. 



186 RACHITIS. 

proximate cause, chemical or other, Gallois thinks will be more clearly 
ascertained.^ 

Anatomical Characters of Rachitis. 

For convenience of description the course of rachitis is divided into 
three periods : (1) That of proliferation and altered nutrition of cai-tilage 
and periosteum; (2) That of curvature and deformity; (3) That of recon- 
struction. 

Anatomical Characters in the Stage of Proliferation and Altered 
Nutrition. — Ossification of a long bone occurs from the epiphyseal cartilages 
and from the periosteal or fibrous membrane which surrounds, nourishes, and 
protects the bone. Growth in length is from the former, in thickness from 
the latter. As regards the flat bone, while growth in thickness occurs from 
the periosteum, that in breadth is from the cartilage of its border, which cor- 
responds with the epiphyseal cartilage of the long bone. 

Cartilaginous Changes. — If we examine the epiphyseal cartilage of 
a long bone during normal ossification, we observe first, beginning at the 
distal end, a white zone consisting of a hyaline matrix, in which are the 
usual cartilage-cells. This constitutes most of the cartilage. Underneath 
this, and nearer the bone, is the zone of iirolifcrafion^ the cartilage in which 
is softer and more yielding than that of the distal zone, in consequence of 
cell-formation and absorption of the matrix to make way for cell-groups. 
Each cartilage-cell in the proliferating zone has divided into two cells, and 
each of these cells into two other cells, and the division has been repeated, so 
that eight cells instead of one are observed, surrounded by a common capsule. 
The capsule becomes distended by the cell-multiplication and by the swelling 
of each cell, the size of which is considerably greater than that of the 
parent cell. Near the bone — namely, along the extremity of the diaphysis — 
the cell-groups, enclosed in their capsules, nearly touch each other, the 
matrix having for the most part been absorbed. The end of the diaph- 
ysis is covered with a layer of these cell-groups about to undergo ossifica- 
tion, with almost no intervening matrix. The proliferating zone has very 
little depth. It appears to the naked eye as a very thin, scarcely per- 
ceptible, layer of a reddish-gray color upon the end of the shaft. It is so 
shallow that it does not perceptibly increase the thickness of the car- 
tilage. 

In rachitis the state of affairs is different. The zone of proliferation, 
instead of being confined to a single, or at most a double, layer of cell-groups, 
consists of many layers involving nearly the whole epiphyseal cartilage. 
The cells, still enclosed in their distended capsules, undergo a more fre- 
quent division than in health, so that instead of groups of eight cells, as in 
the normal state, each group consists of from thirty to forty cells. There- 
fore, in rachitis the proliferating cartilaginous zone is a broad cushion, very 
soft, of a grayish translucent appearance, causing the characteristic swelling- 
observed around the joint. Over the distal end of the proliferating carti- 
lage there may still be a layer or zone, though perhaps of little depth, of 
normal cartilage, like that in health. 

Osseous Changes. — While this occurs the ossifying process is also 
arrested. We indeed perceive an effort in the direction of bone-formation. 
The Haversian canals, surrounded by capillary loops, extend from the bone 
into the proliferating zone of cartilage. Their extension is effected by 
absorption of the matrix and appropriation of cell-groups which lie in their 
way. The cells in these groups as they enter the Haversian system become 

1 Animal of the Univer. Med. Sci., 1889. 



ANATOMICAL CHARACTERS OF RACHITIS. 187 

much smaller b}' a rapid segmentation, forming medullary cells. We also find, 
as further evidence of the attempt at bone formation, granules and masses 
scattered through the cartilage, and here and there spiculse and nodules of 
true bone springing up from the bony substratum of the shaft. Some of 
the canals extend far into the cartilage, nearly, indeed, to its free surface, 
but most of them terminate in its lowest portion. The growth of bone in 
thickness occurs from the under surface of the periosteum. In health a soft, 
vascular, germinal tissue springs from the periosteal surface, and rapidly 
receives lime-salts and is transformed into bone. This general tissue, con- 
sisting largely of capillaries arising from the fibrous tissue of the periosteum, 
is a very thin substratum, barely visible, transient, and constantly changing, 
from its conversion into bone. 

In rachitis this vascular subperiosteal tissue, not undergoing or undergoing 
slowly and imperfectly the osseous transformation, and at the same time 
increasing more rapidly than in health, under the irritating influence of the 
rachitic disease becomes a thick layer. Its color and appearance are like 
spleen pulp, so that the older observers supposed there was a hemorrhagic 
extravasation between the periosteum and the bone. There is, however, no 
extravasation of blood, unless it accidentally occur from the numerous delicate 
capillaries. The resemblance to extravasated blood or spleen pulp is due to 
the abundant growth of large and thin-walled capillaries from the under sur- 
face of the periosteum, as shown by the microscope. The vascular outgrowth 
is, for the most part, quite uniform over the diaphyses of the long bones, 
while upon the cranial bones its thickness is much greater in one locality 
than in another. The attempt at ossification also appears in this tissue. 
Lime-salts are scantily and loosely deposited through it, forming osteo- 
phytes — vascular and fragile — rather than true bone. 

The question naturally arises, How does rachitis aff"ect bone which is 
already formed when the rachitic state begins? Yirchow's answer is the 
following : " Rachitis has .... by more accurate investigation been shown 
to consist, not in a jDrocess of softening in the old bone, as it had previously 
been considered to be, but in a non-solidification of the fresh layers as they 
form : the old layers being consumed by the normally progressive formation 
of medullary cavities, and the new remaining soft, the bone becomes brittle."^ 
It seems, however, from the experiments of Heitzmann, that this opinion 
should be modified, at least as regards rachitis produced by lactic acid. 
Moreover, in rachitic craniotabes occurring in infancy there is certainly bone- 
absorption, for portions of the occipital and parietal bones are absorbed to 
cause the soft spaces. We must therefore believe that there is in rachitis 
more or less absorption of lime-salts in the bone, in addition to that required 
in the normal growth of medullary cavities and canals for vessels. 

In healthy bone the earthy salts are in excess of organic matter nearly 
in the proportion of two to one ; but in rachitis the proportion is reversed, 
the organic matter being much in excess. The following table gives analyses 
of rachitic bones by Marchand, Davy, Boettger, and Friedleben : 





Femur. 


. 


! Radius. 


Vertebra. 




Inorganic. 


Organic. 


Inorganic. Organic'. 

1 


Inorganic. Organic. 













Case I I 20.60 79.40 21.24 78.76 i 18.68 81.32 



Case II. . . . ! 37.80 62.20 'convai.j 20.00 80.00 

Case III. . . . ' 20.89 79.11 ' 

Case IV. . . . j 52.85 47.15 I 



32.29 67.71 



^ Cellular Pathology, Chance's translation, Lecture xix 



188 RACHITIS. 

As might be expected, the relative proportion of organic and inorganic 
matter varies greatly in different cases and at different stages of the same 
case. In severe rachitis many bones are affected. It is stated that there is 
no bone in the entire skeleton that may not suffer, but in mild cases only a 
few are involved, at least to such an extent as to produce structural changes 
appreciable to touch or sight. 

Pathology of Rachitis. 

In this connection it is proper to consider the pafliology of rachitis. 
What is its nature? Niemeyer, in my opinion, expresses the correct view 
when he says, " It seems to me that the most probable hypothesis regarding 
the cause of rachitis is that which refers it to inflammation of the epiphyseal 
cartilages and periosteum." The increased vascularity of the periosteum, 
the proliferation of periosteum and cartilage, the tenderness and pain on 
motion, and the febrile movement in acute forms of the disease, indicate 
inflammation rather than any other recognized pathological state. The 
rachitic inflammation, as it affects the osseous system, appears to be of a 
chronic or subacute character, presenting an analogy with certain other well- 
known inflammations, such as cirrhosis and certain forms of chronic nephritis, 
in which proliferation of connective tissue and sclerosis occur. The eburna- 
tion rather than normal ossification which terminates the rachitic process may 
properly be considered an osteosclerosis. Conformably with the theory of 
the inflammatory nature of rachitis, the periosteum is found infiltrated and 
thickened, and of a reddish hue from hyperasmia and from the presence of 
the newly-formed capillaries underneath, which have been described above as 
forming a layer of considerable thickness known as the '• germinal vascular 
tissue." Moreover, as in inflammation, some secretion along with the vascu- 
lar growth occurs over the bone from the under surface of the periosteum. 
The various interspaces in long, short, and flat bones, the diploe, cancelli, and 
interlamellar openings, contain a substance similar to that exuded under the 
periosteum. It appears to be an inflammatory exudation. 

Anatomical Characters in the Stage of Deformity. — Rachitic bone, 
when the disease has continued for some time and is still in its active period, 
presents a bluish or dusky-red appearance, from its increased vascularity. 
After a variable time, weeks or months according to the severity of the 
disease, deformities begin to appear. 

Spiegelberg's description of the appearance of the rachitic foetus cor- 
responds for the most part with what I observed in the one whose skeleton 
is represented in Fig. 10. According to this writer, the body and limbs are 
plump, the latter short and curved ; the abdomen large and prominent ; and 
the head sometimes hydrocephalic. The skin is thick and loose, and the adi- 
pose tissue well developed; the liver large; the epiphyses swollen and soft; 
the short and curved diaphyses sometimes broken. The rotundity of the 
thorax is preserved, and the sternum is not carried forward, since there has 
been no respiration ; the ribs, in softness and liability to fracture, correspond 
with the long bones of the extremities. The sternum, most of all the bones, 
shows the delay in ossification ; the clavicle is among those least affected. 
The cranium may be represented by a membranous bag with phiques of 
bone, or the cranial bones may be formed and in shape, but thickened and 
softened ; the sacral promontory is pressed forward and downward ; the sa- 
cral vertebrae flattened ; the ilia flattened and widened ; and the pubic arch 
increased. 

It is interesting to compare these deformities with those in the child, since 
they occur under conditions so very different. Rachitic bone seldom retains 



PATHOLOGY OF RACHITIS. 189 

its normal form or shape ; its projecting points are rounded, and as soon as 
it softens it begins to yield to pressure exerted upon it. Hence the curva- 
tures so common and characteristic. The portion of a long bone which is 
formed after rachitis commences contains so little earthy matter that it bends 
readily in its fresh state, either by muscular action or by the weight of the 
trunk, "in the manner," says A^ogel, " of a quill or willow stick." The inte- 
rior of the bone, which was formed Ibefore rachitis began, and which contains 
nearly or quite the normal proportion of lime, is likely to break instead of 
bending, but, as it is surrounded on all sides by the soft tissue, the fragments 
are not displaced, and probably do not crepitate. So scanty is the calcareous 
deposition in typical cases that, says Trousseau, •• the bones .... can be 
cut with a knife with as much ease as a carrot or other soft root." and the 
dried specimen weighs but one-sixth to one-eighth as much as normal bone. 
One writer states that the dried rachitic bone is sometimes so porous, from 
the small amount of lime which it contains, that it is possible to respire 
through it as through a sponge. 

In ordinary cases the bones which exhibit most strikingly the rachitic 
change, and which, therefore, should be carefully examined in making the 
diagnosis, are the cranial bones, the ribs, and the radius — the sternal ends of 
the ribs and the lower end of the radius. It is seldom that these bones do 
not give evidence of the disease if it be present, and in greater degree than 
other bones. They are the first to be afi'ected to an extent that is appre- 
ciable to the observer. 

Changes in the Cranial Bones. — In these bones interesting and 
important alterations occur. Their edges, which correspond with the epi- 
physeal cartilages, undergo proliferation and become thickened like the latter. 
This thickening and the delayed union of the sutures produce grooves which 
can be traced by the fingers between the bones, and which are sometimes 
appreciable to the sight. Rachitis causes some enlargement of the cranium, 
but the enlargement seems greater than it really is on account of the retarded 
growth of the facial bones. In a discussion on rachitis in the London Patho- 
logical Societ3^ reported in the Lancet^ it was stated that in 17 rachitic chil- 
dren, with an average of 4.72 years, the average circumference of the head 
was 21.22 inches, while in the same number who were non-rachitic and with 
an average of 6.05 years, the average circumference was 19.95 inches. 

The retarded ossification is manifested not only in the open sutures, but 
also in the large size and patency of the fonfaneh, which are not closed till 
long after the usual time. The anterior fontanel should be closed between 
the fifteenth and twentieth months, but in the rachitic it remains membra- 
nous till after the second year, even into the third or fourth year. Since 
examination of the anterior fontanel is important in determining whether 
or not rachitis be present, it should be borne in mind that in the normal state 
this space increases in size till the seventh month, when it is at its maximum, 
and that after the ninth month it becomes progressively smaller. 

The shape of the rachitic head varies. In general, instead of its normal 
rounded form, it approaches a square shape. Another type is sometimes 
observed in which there is no marked angularity, but in which the antero- 
posterior diameter is enlarged. In the square head the forehead projects and 
both the frontal and parietal protuberances are unusually prominent. The 
sutures are depressed to a certain extent, as has already been mentioned, and 
the anterior, lateral, superior, and posterior surfaces of the cranium are more 
flattened than in health. The lambdoidal suture, which should close by the 
fourth month, and the sagittal, which should close by the end of the first year, 
have made little progress toward union when the second year begins. The 

^ Lancet, 1880, vol. ii. p. 1017. 



190 RACHITIS. 

undue prominence of the frontal and parietal bosses takes its origin from the 
exaggerated proliferation of the periosteal or fibrous covering of the bones. 

Craniotabes. 

Thinning of the cranial bones in places so that the brain lacks proper pro- 
tection has long been noticed in the examination of rachitic heads, but the 
injury that results to the infant was overlooked till pointed out by Dr. Elsas- 
ser. Craniotabes occurs for the most part in patients under the age of one 
year, and a large proportion are under eight months. Its occurrence in the 
foetus, as shown by a case published in the New York Obstetrical Journal m 
1870 and by Heitzmann's case, has already been alluded to. The factors in 
producing this thinning are rachitic softening of the bones and pressure — pres- 
sure of the brain from within and of the pillow from without. Consequently, 
the portions of the cranial arch in which the thinning occurs are the posterior 
and lateral, the occipital bone and the posterior half of the parietal. If the 
infant lie chiefly on one side in its crib, on this side the craniotabes occurs, 
while those portions of the cranium which are not pressed upon, as the frontal 
bone, exhibit no thinning. The soft spots are yielding when pressed upon, 
and in the cadaver they are seen to be translucent when held to the light. 
The amount of absorption varies greatly according to the degree of rachitic 
softening and the amount and continuance of the pressure. There may be 
in some instances simple depressions, like erosions in the bone, with a contin- 
uous but thin bony layer remaining ; but in other cases, such as have been 
particularly examined and studied by physicians, the bone-absorption is com- 
plete over areas of greater or less extent, so that the pericranium and dura 
mater are in contact. In examining a child for craniotabes it should be borne 
in mind that the margins of the bones, even when there is no thinning, but 
thickening from the cartilaginous proliferation, are flexible in the rachitic. 
The pressure must be made in a direction from the sutures, to ascertain 
whether craniotabes has occurred. The pressure should at first be made 
lightly and cautiously with the fingers, for if there be total absence of bone, 
unless of very little extent, deep and forcible pressure might injure the brain,, 
for so soft and delicate an organ, covered only by the scalp and dura mater, 
badly tolerates pressure. If the first examination detect no soft place, the 
fingers may be pressed more firmly against the scalp, when, if the bone be 
much thinned, so that there is only a small layer of the lime-salts underneath, 
it will be found to yield. The sensation communicated to the fingers when 
there is an open space in the cranium and the dura mater and scalp are in 
contact has been likened to that experienced when pressing upon a fully-dis- 
tended bladder. At a meeting of the London Pathological Society, reported 
in the Lancet for November 20, 1880, Dr. Lees presented statistics to show 
that craniotabes was one of the lesions of inherited syphilis ; but whether it 
may result from syphilis or not, the evidence that there is a cranial softening 
which is strictly rachitic appears from repeated observations to be sufficient. 

Symptoms of Craniotabes. — As craniotabes gives rise to peculiar symp- 
toms quite distinct from those of the general rachitic disease, they may be 
properly considered in this connection. Craniotabes usually occurs during 
the first year of infancy, and most frequently prior to the tenth month. The 
brain at this age is soft and yielding, since it contains a large percentage of 
water. Unless handled with care at an autopsy it is readily lacerated, and 
moderate pressure upon it is seen to disturb and move it a considerable dis- 
tance from the point of contact. It assists to a proper understanding of the 
symptoms of craniotabes to recall to mind the fact, well known to surgeons, 
that slight depression of even a small portion of the skull usually produces 



CRANIOTABES. 191 

grave symptoms. It is not surprising, therefore, that craniotabes, when 
there is a space of considerable size in the cranial arch destitute of bone, 
is attended by symptoms due to the mechanical effect of external pressure 
whenever a substance less yielding than the brain comes in contact with the 
unprotected part. 

Since pressure from the pillow without and from the brain within is 
believed to be the cause of the absorption, the craniotabes must obviously 
occur in the posterior and postero-lateral portions of the cranium. Cor- 
responding with this explanation of the causation, the thinning actually 
occurs in the occipital and posterior portions of the parietal bones, while the 
anterior halves of the parietal bones and the frontal bones are even thicker 
than normal, from the cartilaginous and periosteal proliferation occurring 
along the sutures and on the surface of these bones, as already described. 
It is well known that long-continued pressure produces absorption of cal- 
careous matter even more readily than of soft tissues, as is shown in the 
absorption of a tooth of the first set by the growth of the dental pulp of the 
second set. In the normal growth of the skull constant absorption of the 
under surface of the cranial bones is going on to make room for the enlarg- 
ing brain, and when no calcareous deposition occurs upon the external sur- 
face to compensate for the loss within, we might expect even a greater amount 
of craniotabes than ordinarily occurs. 

Every rachitic infant is fretful, but one with craniotabes is especially so 
if the open spaces be of considerable size. If it lie upon the pillow in its 
accustomed manner, as is most natural for it, the unprotected portion of the 
brain may be so pressed upon by the weight of the head that it feels uncom- 
fortable. It does not have quiet sleep, probably because the cerebral circula- 
tion and functions are in a measure disturbed ; it is apt to awaken readily 
and often, and frets till it is taken in the nurse's arms. Sometimes it instinct- 
ively seeks a position on the edge of the pillow with the face downward, and 
it becomes more quiet when resting over the nurse's shoulder with the face 
backward. But if fretfulness, disturbed sleep, and the necessity of closer 
attention on the part of the mother and nurse were the only ill-effects of 
craniotabes, it would possess much less pathological significance than pertains 
to it. Pressure upon so delicate and important an organ as the brain involves 
risks and produces serious symptoms in proportion to its degree. Even a 
slight injury of the skull which produces depression, though it may be of 
trifling amount, will cause serious forms of nervous disorder. So craniotabes 
is believed to sustain a causative relation in certain cases to one of the most 
dangerous of the neuroses— namely, laryngismus stridulus, an affection which 
is also designated " internal convulsions," " spasm of the glottis," and "Kopp's 
asthma," although Kopp was not the first to describe and recognize the mal- 
ady. The etiology of this neurosis has not been fully elucidated. It is cer- 
tain that a large proportion of those who suffer from it are rachitic, and that 
it is more common and severe where rachitis is prevalent, as in England, than 
where it is rare, as in the rural districts of America. It is not often the 
cause of death in this country, and the fatal cases that do occur are only seen 
in cities, whereas in parts of Europe where rachitis is much more common 
than with us it causes many deaths. 

Certain infants when in a state of excitement have what are termed 
" holding-breath spells.'' The face is flushed and breathing ceases for some 
seconds, after which respiration returns and is normal. These attacks are 
unimportant, but they appear to be the same in nature with the more severe 
and dangerous seizures of laryngismus stridulus. They have no pathological 
significance, excepting as they show the same neuropathic state as that in 
laryngismus, and as they may be precursors of this disease. Laryngismus 



192 



RACHITIS. 



stridulus, or glottic spasm, is usually preceded by more or less impairment of 
the general health, and often by fretfulness, which is characteristic of the 
rachitic state ; but the attack occurs suddenly, without premonition, and is 
of short duration. It begins with an arrest of respiration, a true apnoea, as 
if from paralysis of the respiratory centre in the medulla. The lips may be 
livid ; a pallor spreads over the face ; sometimes more or less rigidity of the 
limbs occurs, with carpo-pedal contractions ; and after a few seconds, a quarter, 
or half minute a long and deep but difficult inspiration through the narrow 
chink of the glottis follows, accompanied in many patients by a whistling or 
crowing sound, and the attack ends with perhaps a momentary look of 
bewilderment or dread on the child's face. Now, this disease, like eclampsia, 
does not have a uniform causation. In certain cases it appears to be a reflex 
phenomenon due to an irritant in some part of the system, as in the intestines ; 
but many observations have established the fact that rachitis also sustains 
a causal relation to it. A large proportion of the infants affected with 
laryngismus exhibit unmistakable rachitic signs, and in the opinion of many 
experienced observers the exposed state of the brain aftbrds explanation of 
the fact that so many of the rachitic have this neurosis. Still, from observa- 
tions which I have made, and from those of other observers, like Senator, it 



Fig. 1 




Head of a Rachitic Child in the New York Infant Asylum. 



is certain that laryngismus stridulus is common in the rachitic who do 
not have craniotabes, so that there must be a causal relation in rachitis to 
laryngismus independently of the cranial softening. The accompanying 
woodcut represents the rachitic head of a child in the New York Infant 
Asylum. This patient had also attacks of laryngismus stridulus. 

Changes in the Vertebra, etc. — The short bones which participate in 
the rachitic disease become softer and more yielding, and their cancelli are 
filled with a reddish pulpy substance. In many rachitic cases the vertebrae 
are but slightly involved, so that no deformity of the spinal column results ; 
but occasionally, when many bones are affected, the vertebrae and interver- 
tebral cartilages soften and spinal curvatures result. The curvatures are due 
to the weight of the shoulders and head on the spinal column. They are, 
with some deviations, an exaggeration of those present in the normal state. 



CRANIOTABES. 



193 



Fig 



Rachitic curvatures of the spine are therefore mainly antero-posterior with 
some lateral deflections. Where there is much curvature the vertebrse 
become wedge-shaped, narrowed upon the concavity, and thickened upon the 
convexity. The intervertebral cartilages are also more or less changed by 
the pressure, being thinned where the vertebra approximate to each other on 
the concave aspect of the curvature, and of normal thickness or thicker than 
normal upon the convexity. The accompanying woodcut exhibits the nature 
and appearance of rachitic spinal curvature in the adult. Rachitis, having 
occurred at the usual age, resulted in the perma- 
nent deformity here illustrated. In extreme cases, 
fortunately rare, the functions of important organs 
may be seriously impaired by the curvature and 
consequent compression, as in Pott's disease. Thus, 
according to Miller, the aorta has been so doubled 
upon itself as to diminish materially the flow of 
blood to the lower extremities and sensibly impair 
their nutrition. The eff"ect of so great curvature 
upon the functions of the heart and lungs must 
obviously be detrimental. 

At first the spinal curvatures disappear when 
the child reclines or is lifted by the axillas, so as 
to raise the head and shoulders from the spine, but 
when the deformity has continued so long that the 
vertebrge and cartilages have become wedge-shaped, 
it remains for life, or can only be rectified slowly 
and with difficulty by mechanical appliances. As 
seen in the woodcut, the common curvature in the 
dorsal region is backward (Jxi/phosis)^ while to com- 
pensate the patient instinctively carries the neck 
forward, with the head thrown back, causing cer- 
vical lordo.ns, a similar anterior curvature being 
common in the lumbar region. Lateral curvature 
(scoliosis') may or may not be present, even when 
there is considerable antero-posterior flexure. Sco- 
liosis is sometimes produced by the nurse in carry- 
ing the infant habitually over one arm. 

Changes in the Maxilla. 
which rachitis produces in the maxillary bones. Stunted growth of the facial 
bones generally has long been known, and has been remarked upon by various 
writers ; but according to Fleischmann other interesting changes occur in the 
jaw-bones which aflect the direction and position of the teeth. According to 
this author, the arched shape of the lower jaw becomes polygonal, and the 
direction of the alveolar process also changes, so that it inclines inward. 
This deviation in the arch and in the alveolar process, which begins in the 
region of the canine teeth, necessarily causes shortening of the lower jaw. 
Commencing soon after, a change is observed in the upper jaw-bone from the 
zygomatic arch forward, so as to cause lengthening of this bone, changing 
here also the shape of the arch and the position of the teeth. The lateral 
incisors, instead of being in front, have a lateral position, and the incisors and 
molars diverge, so that when the jaws are closed they overlap the correspond- 
ing teeth of the lower jaw in front and upon the sides — a condition the oppo- 
site of that seen in the jaws of old people. Fleischmann attributes these 
changes in the lower jaw to the action of the masseter and mylo-hyoid mus- 
cles, and perhaps the genio-glossus. and to pressure of the lip, the deficiency 
of earthy salts in the bone rendering it more easily acted on by the muscles. 
13 




Rachitic Spinal Curvature 
in an Adult. (From a speci- 
men in the "Wood Museum, 
Bellevue Hospital.) 



Fleischmann has investigated the changes 



194 . RACHITIS. 

The change in the upper jaw-bone he attributes to lateral pressure of the 
zygomatic arches. 

Changes in the Ribs. — The ribs are early affected in rachitis. The 
swelling of their anterior ends, where they unite with costal cartilages, pro- 
ducing the " rachitic rosary," has been already alluded to as one of the first 
and most conspicuous signs of rachitis. The costochondral articulations are 
enlarged in all directions, appearing as nodules under the skin. If an oppor- 
tunity occur of inspecting, at an autopsy, the pleural surface, the nodular 
prominences are seen to be even greater and more distinct there than under 
the skin. 

The deformity of the thorax consequent upon softening of the ribs is 
interesting. Commencing with the spine, the ribs extend nearly directly 

Fig. 13. 



Rachitic Child with characteristic Deformity of Head, Ribs, and Radius. (From a patient in the 

New York Foundling Asylum.) 

outward ; at the union of the dorsal and lateral regions, they make a short 
curve forward, and then turn inward, also with a short curve toward the 
sternum (Fig. 14). This abrupt bending of the ribs — which, in their soft- 
ened state, has been caused by atmospheric pressure during respiration — pro- 
duces a depression in the thoracic wall at about the point where the ribs and 
their cartilages unite. A groove extends on the antero-lateral surface of the 
thorax from the second or third rib downward and a little outward. Some- 
times the bottom of the groove is occupied by the costochondral joints; in 
other cases these joints are a little to one side of the deepest part of the 
groove. The transverse diameter, therefore, of the anterior half of the 
thorax is much less than in health. This necessarily diminishes the lateral 
expansion of the lung in inspiration and causes unusual prominence in the 
sternum. Hence the expressions " pigeon-breasted," ■' resemblance to the 
prow of a ship," etc., applied to this deformity. The presence of the heart 
renders the groove more shallow on the left side, at the fourth and fifth ribs, 
than on the opposite side, since this organ affords partial support to the chest- 
wall. On the other hand, the right groove is not as long as the left, as the 
lower ribs on this side are partially supported by the liver. On both sides, 
however, the lower part of the thorax, that below the seventh, eighth, or 
ninth ribs, widens, being pressed outward and supported by the abdominal 



CRAXIOTABES. 



195 



viscera. There is, therefore,' in addition to the longitudinal groove, an 
antero-posterior depression, sometimes also spoken of as a furrow or groove, 
on either side, lying between the sixth and ninth ribs. 

The ribs with their attached muscles are important agents in respiration, 
but the soft and yielding nature of the ribs in the rachitic retards, and to a 




Deformity of Chest and Rachitis. 

great extent prevents, the lateral expansion of the thorax which is necessary 
for normal and full inspiration. The action of the respiratory muscles, and 
the pressure from within of the air descending along the air-passages, is not 
sufficient to overcome fully the external atmospheric pressure in the absence 
of proper resiliency of the ribs. Consequently, with each inspiration we 
observe more or less sinking in of the thorax on either side, just as when a 
moderate obstruction to the entrance of air exists in the larynx or trachea. 
As the ribs become firmer from the deposit of lime-salts, respiration is more 
regular and normal. 

Changes in Bones of Upper Extremity. — Although swelling of the 
lower end of the radius (see Fig. 13) is one of the earliest signs of rachitis, 
the bones of the upper extremities are less frequently curved and distorted 
than those of the lower extremities. The clavicle sometimes softens and 
bends, producing two curvatures — one backward, near the scapula, and 
another of larger size nearer the sternum, directed forward and a little upward. 
Careful examination shows, in some rachitic patients, thickening of the margins 
of the scapula, like that of the cranial bones. The humerus is occasionally 
bent, and usually at the point of insertion of the deltoid, in consequence of 
the powerful action of this muscle in raising and supporting the arm. The 
radius and ulna are bent outward and twisted. The deformity is attributed 
by Sir William Jenner to the fact that rickety children support themselves, 
while in the sitting posture, upon the palms of the hands pressed upon the 



196 



RACHITIS. 



floor or couch. Supporting the weight of the' body in this way not only, in 
his opinion, causes bending of the ulna and radius, but also aids in producing 
the deformities of the humerus and clavicle. 

Changes in Bones of Pelvis. — The deformities of the pelvic bones 
resulting from rachitic softening are, in the female infant, the most important 
of any which the skeleton undergoes. They are produced by pressure from 



Fift, 



Fig. 17. 




Rachitic Deformities of the Pelvis. (From specimens in the Wood Museum.) 



above of the abdominal organs, serving to widen the brim of the pelvis, and 
also by pressure of the spinal column, sustaining the weight of the trunk, 
shoulders, and head, pressing forward the promontory of the sacrum in the 
sitting posture, and thus diminishing the antero-posterior diameter of the 
pelvic brim. There is, moreover, twofold pressure from below — that caused 
by the heads of the thigh-bones in standing, and that exercised by the 
tuberosities of the ischia in sitting. Both these forms of pressure have a 
tendency to narrow the outlet of the pelvis. Hence the marriage of the 
female who has been rachitic in infancy may involve serious consequences. 
Many of the tedious instrumental labors in the families of the city poor, 
which severely tax the patience and endurance of young practitioners, are 
attributable to rickets in early life. 

Changes in Bones of Lower Extremities. — The curvature of the 
femur is usually forward or forward and outward. The neck of the femur 
sometimes bends by the weight of the body or by use of the legs, so that the 
angle which it forms with the shaft is chang:ed. The annexed woodcuts show 



Fig. 18. 



Fig. 19. 




Rachitic Deformities of the Femur. (Wood Museum.) 



the rachitic bend of this bone in an adult years after rachitis had ceased and 
when the bone had become consolidated by the new deposition of lime-salts. 
The curvature of the tihla Siud/ihtki varies. In those under the age of 
one year it is frequently outward, so that the knees are separated from each 
other. In those old enough to stand the weight of the body usually deter- 
In one case in my practice an 



mines also a forward bending of these bones 



CRANIOTABES. 



197 



anterior curvature so abrupt that an angle of about 70° was formed existed 
about four inches above each ankle. This patient, though old enough to walk, 
almost constantly sat during the day with the feet extended beyond the sofa, 
so that the edge of the latter corresponded with the concavity of the legs. 
It seemed to me that the weight of the feet must have been a factor in caus- 
ing these curvatures, especially as the case was one of very marked rachitic 
softening of different bones. Still, tibial and fibular bending at this point 
has been noticed by different observers, who have attributed it to the weight 
of the body in walking. Various other curvatures besides those mentioned 
occur in the bones of the lower extremities, the direction in which the limbs 
bend being determined by the particular circumstances of the case. 

In mild cases of rickets most of the deformities described above are lack- 
ing, but in typical cases certain of them stand out prominently, so as to be 
readily detected by one familiar with the disease. In all such cases the 
diagnosis is easy beyond that of most other maladies, for the changes which 
occur are not only conspicuous but pathognomonic. 

Rachitis produces another important effect on the skeleton. Its growth 
is stunted^ not only during the rachitic period, but subsequently, so that those 
who have been rachitic in childhood, unless very mildly, have less than the 
average stature in adult life. The stunted growth is apparent, though ample 
allowance be made for curvatures. The arrest of development is greater in 
some bones than in others. It is greatest in the bones of the face, pelvis, 
and lower extremities. Stunted growth of the pelvic bones of the female 



Fig. 20. 



Fig. 21. 



Eachitic Deformities of the Femur, Tibia, and Fibula. (Wood Museum.) 

infant, conjoined with the deformities alluded to above, may seriously affect 
her subsequent life, and a rachitic pelvis in the female, exhibiting both 
stunted growth and deformity, constitutes a valid reason for avoiding mar- 



198 RACHITIS. 

riage. As a rule, the older the child is when rachitis begins the less is the 
skeleton affected, and the less, consequently, is the deformity. 

Effect of Rachitis on Dentition. — As might be expected from the 
nature of rachitis, dentition is delayed. If the disease show itself before 
any tooth has appeared, the first teeth — to wit, the lower central incisors — 
will probably not appear before the ninth or tenth month, or even later. Sir 
Wm. Jenner considers the non-appearance of a tooth by the ninth month, 
with few exceptions, a sign of rachitis. Teeth which appear during the 
rachitic state are frail, deficient in enamel, and crumble readily. They 
become carious, rot, and break before the usual time. If certain teeth have 
appeared when rachitis begins, several months elapse before others cut the 
gum. It is even said that a child who has rachitis severely may never 
have a tooth, may remain toothless for life, but I have never observed 
such a case. Ordinarily, when the rachitic state ceases and the health 
is fully restored, dentition goes on as before. The arrest of teething, so 
easily observed, has long been considered one of the most reliable diag- 
nostic signs. The physician cannot justly pronounce on the nature of the 
disease in a case of suspected rachitis unless he first carefully inspects the 
gums. 

Changes in the Soft Tissues. — Although the conspicuous lesions of 
rickets pertain to the skeleton, the soft tissues are also more or less implicated. 
The ligaments become relaxed and flabby, giving unusual mobility to the 
joints and unsteadiness to the movements. The fibrous bands which unite 
the vertebrae, as well as the ligaments of the extremities, participate in the 
relaxation. In certain patients the muscles throughout the system — partly, 
perhaps, in consequence of the gastro-intestinal disturbance, indigestion, and 
malnutrition ; partly, perhaps, for want of use (for the rachitic are usually 
quiet) — become shrunken and flabby. The spleen is frequently enlarged, as 
ascertained by palpation and percussion. Ritter von Rittershain found this 
organ decidedly enlarged in 10 out of 35 cases which he examined after 
death. The enlargement is the result of cellular proliferation, common in 
diseases which are attended by dyscrasia. The liver in many patients under- 
goes no perceptible change, except that it may be pushed a little downward. 
It is occasionally found enlarged from fatty infiltration, but no special sig- 
nificance attaches to this, for fatty liver is common in various forms of 
disease attended by innutrition and wasting. It is common in tuberculosis 
and in protracted intestinal catarrh, and its pathological significance appears 
to be the same in these various diseases. There can be little doubt that Sir 
Wm. Jenner errs when he states that albuminoid infiltration of the liver is 
common in rachitis. Parry, Gree, Dickinson, and Senator agree that it is 
rare, and that if it does occur it is by coincidence. 

In a discussion on rachitis in the London Pathological Society, Dr. Dick- 
inson^ spoke of enlargement of the spleen, liver, and lymphatic glands 
which he had observed in rachitic cases. According to him, the spleen 
undergoes the greatest enlargement, the lymphatic glands the least, and of 
the latter, " the mesenteric glands show the most decided swelling." The 
spleen in some patients has been so large that it occupied the greater part 
of the left half of the abdominal cavity, but a less degree of enlargement is 
the rule. The liver frequently extends one or two inches below the ribs. Its 
enlargement, Dr. Dickinson adds, is not amyloid. " There is no new growth or 
deposit, only an irregular development of the proper tissues of the organs." He 
believes that both the corpuscular and interstitial elements are increased in 
the liver, spleen, and lymphatic glands. But other members of the society 
had observed this enlargement only in occasional cases, and they considered it 
^ iawceL December 11, 1880. 



CRANIOTABES. 199 

due rather to the state of health which caused rachitis than to rachitis itself. 
Dr. C. Hilton Fagge stated that he had failed to find swelling of the liver, 
spleen, or lymphatic glands in a large majority of cases. ^ An undue devel- 
opment of the lymphatic glands from hyperplasia is very common in chil- 
dren in various states of ill-health, and the mesenteric glands are especially 
liable to become enlarged from this cause in protracted cases of intestinal 
catarrh or irritation. 

The abdomen is protuberant from various causes. The lateral depression 
of the thoracic walls causes the liver and spleen to descend a little lower in 
the abdominal cavity than natural. The enlargement of the liver and 
spleen, the feeble tonicity of the intestinal muscular fibres, and consequent 
distension of the intestines with gas. and the rachitic shortening of the 
spinal column, which causes approximation of the ribs and pelvis, necessarily 
produce abdominal protuberance. 

The kidneys, themselves are not diseased in rickets, but there is an exag- 
gerated discharge of phosphates in the urine, and, as stated above, lactic acid 
and free phosphoric acid have been found in this excretion. The urine is 
commonly pale ; its urea and uric acid are diminished ; and it sometimes con- 
tains a sediment of oxalate of lime. 

The brain is usually well developed and appears healthy, with the normal 
proportion of white and gray substance. In one case the weight of this organ 
was ascertained by Dr. Gree to be fifty-nine ounces, and in another forty-two 
and a half ounces. In both brains the proportion of white and gray sub- 
stances, and their color and consistence, seemed normal. 

Anatomical Characters of the Third Stage, or that of Recon- 
struction. — This stage will be better understood if we recollect what has 
occurred during the first and second stages. The vascular periosteum is 
drawn tightly over convexities, the pressure upon which diminishes the 
hyperaemia and the amount of exudation underneath. Over the concavities 
the periosteum is loose ; it is hyperaemic, with abundant new capillaries, the 
interspace between it and the bone being filled with the gelatiniform sub- 
stance already described. The reparative process goes forward more rapidly, 
and the deposition of lime-salts is more abundant upon the concave surfaces, 
where there have been free exudation and no compression of the capillaries, 
than elsewhere. The lime-salts are deposited from the blood. Consequently, 
from the increased capillary circulation and hyperaemic state of the perios- 
teum produced by rachitis the chalky matter is rapidly effused wherever there 
is an open space under the periosteum and where the capillaries are in a state 
of engorgement. Hence the reconstructed bone is thicker and firmer upon 
the concave aspect of the long bones than elsewhere, and thinnest upon the 
convex aspect, where the periosteum is more tense and its capillaries more or 
less compressed. 

It is a question whether true ossification occurs at first during the repar- 
ative stage. The deposition of chalky matter is designated by some writers 
as a petrifaction rather than a true bone-formation. Trousseau likens it to 
the formation of callus after a fracture. It certainly produces a substance 
more compact than ordinary bone. The term " eburnation " has been applied 
to this new osseous formation, and I have designated it " osteo-sclerosis." 
Some years since I examined microscopically an adult bone which exhibited 
the rachitic curvature in a marked degree, and was very hard. It contained 
the elements of true bone, but it may have been produced after the rachitis 
had ceased and in the subsequent growth. 

Recovery from rickets is gradual. Little by little the cartilaginous and 
periosteal proliferation ceases, the hyperaemia abates, and the bone-producing 

J Lancet Xovember 20, 1880. 



200 RACHITIS. 

tissues return to their normal state. Certain of the deformities are perma- 
nent, but others disappear in the further growth of the skeleton. 

Symptoms of Rachitis. 

Preceding and accompanying rachitis, symptoms may be present which 
are due to indigestion and intestinal catarrh, such as flatulence, unhealthy 
stools, and poor or capricious appetite. When rachitis begins the infant 
becomes fretful ; its sleep is frequently restless and disturbed, and it awakens 
often. It repels attempts to amuse it, and is apparently annoyed by them. 
Nurse and mother speak of it as a cross child. It perspires freely from the 
head and neck both when awake and when asleep, while the extremities and 
trunk are dry. Its pillow is wet with perspiration during sleep, and sweat- 
drops may be seen upon forehead and face. If the surface be dry a little 
excitement or elevation of temperature causes the perspiration to appear. 
The rachitic child does not well tolerate the bed-clothes, and attempts to throw 
them off from its limbs, even in cool weather, lying exposed and causing 
considerable annoyance to the nurse, who strives to prevent its taking cold. 
Sometimes miliaria, due to the moist state of the skin, appear upon the face 
and neck. The subcutaneous veins which return blood from the head are 
large, and the jugular veins full. 

Another symptom is soon observed — to wit, tenderness over a consider- 
able part of the surface, perhaps largely due to the morbid state of the peri- 
osteum over so many bones, though it is also experienced when pressure is 
made upon the soft parts of the abdomen. The tenderness is probably, in 
part, the cause of the fretful disposition. The little patient appears to 
dread to be touched ; its flesh is sore ; it repels attempts to amuse it, and 
wishes to be quiet. Dandling it upon the arms, swinging it, or even walking 
with it, which delights the healthy child and elicits a smile of satisfaction, 
only adds to its discomfort. It is most at ease when left alone upon a soft 
cot or pillow, or, if it have craniotabes, when quietly held over the shoulder. 
Languor, disinclination to use the limbs or to play, moderate thirst, with other 
symptoms referable to the digestive apparatus which are present in many cases 
and which have already been described, are soon followed by changes in the 
skeleton which are perceptible to the sight and on palpation. The pulse and 
temperature, in a large proportion of the ordinary chronic cases, do not devi- 
ate from the healthy state, except that in some patients there is a slight 
febrile movement in the latter part of the day. 

Although rachitis is ordinarily a chronic disease, insidious in its com- 
mencement, gradual and progressive in its development, occupying months, 
there is an acute form which is attended by more marked febrile movement 
and tenderness, and in which the articular swelling appears more quickly. 

A hiniit de soufflet of greater or less intensity, synchronous with the pulse, 
has frequently been heard in rachitic cases by applying the ear over the ante- 
rior fontanel. Drs. Whitney and Fischer, New England physicians, first 
called attention to this murmur, believing it to be a sign of chronic hydro- 
cephalus. MM. Rilliet and Barthez heard it in cases of rachitis, and there- 
fore concluded that the American physicians had confounded the two diseases. 
More recent observations have established the fact that this bruit has little 
diagnostic value. It is heard whenever there is sufficient patency of the 
anterior fontanel, both in health and disease, for sound is conducted better 
through a membrane than through bone. Dr. Wirthgen heard the bruit in 
22 out of 52 children, of whom all except 4 were in good health. I have 
auscultated the anterior fontanel in 29 infants, who were with 2 exceptions 
between the ages of three and thirty months. All were well or had merely 



DIAGyOSIS OF RACHITIS. 201 

trivial ailments which did not affect the cerebral circulation. In most of 
them a murmur could be distinctly heard synchronous with the respiratory 
act, and in 15 of the 29 cases no other sound could be detected, while in the 
remaining 14 a bruit could be detected synchronous with the pulse. 

Complications and Sequels of Rachitis. 

These have been in part described in the foregoing pages, but there are cer- 
tain other results of the disease to which it is proper to call attention. If the 
deformity in the thoracic wall — namely, the lateral depression of the ribs and 
anterior projection of the sternum — be great, we would naturally expect that 
the two important organs underneath, the heart and lungs, would receive 
some detriment. Upon the surface of the hearty at the point where it sup- 
ports the softened ribs, a white patch is often found, due to thickening of the 
pericardium and proliferation of the endothelial cells, just as thickening of 
the skin in the palm of the hand occurs from friction and pressure upon that 
part. It is probable that this pressure does not seriously impair the function 
of the heart, but it may increase the weakness of its movements in any 
asthenic disease which may occur during the rachitic period. The injury 
sustained by the IiinrjF; is greater and more apparent. If the ribs be flexible 
and much depressed, full inflation of the lung cannot occur in those parts 
where the depression is greatest. Semi-collapse of certain lobules is liable to 
occur, and even complete collapse of the thin edges of the lung. The stress 
of respiration falls unequally upon different parts of the lung. The anterior 
portion, which ascends with the sternum as that is propelled forward, is more 
fully dilated than the lateral and posterior parts, and hence is liable to become 
emphysematous. If in this state of the thorax and lungs severe bronchitis 
or broncho-pneumonia arise, the state is one of great peril. The mucus and 
pus, being expectorated with difficulty, clog the tubes and produce dyspnoea. 
Full inspiration in the lateral and depending portions of the lung, which is 
required in order to expel these secretions, not occurring, the result may be 
unfavorable, even in comparatively mild forms of inflammation. Bronchitis 
and broncho-pneumonia are the causes of death in not a few cases of severe 
rickets. Certain writers state that chronic hydrocephalus, diarrhoea, and 
eclampsia may complicate rachitis. I have not seen any case in which 
rickets seemed to sustain a causative relation to either hydrocephalus or 
diarrhoea, but we know that diarrhoea frequently precedes and accompanies 
rachitis, and its relation to it is that of cause rather than effect. This sub- 
ject has been sufficiently treated of in preceding pages. Eachitic infants 
appear to be more liable to eclampsia than those who are healthy. This 
would be inferred from their liability to laryngismus stridulus. 

Diagnosis of Rachitis. 

Eachitis in many instances continues a considerable time before its nature 
is suspected, the symptoms to which it gives rise being overlooked or attrib- 
uted to other causes than the true one ; and yet it is important that an early 
diagnosis be made, for it is much more amenable to treatment in its early 
than in its later stages. The deformities which mar the beauty, and to a 
certain extent impair the activity and usefulness, of so many who have been 
rachitic in childhood may often be prevented by early diagnosis and treat- 
ment. Many with this disease do not show the usual signs of faulty diges- 
tion and innutrition, especially on casual inspection, for there may be consid- 
erable adipose development and rotundity of features and form in a rachitic 
child ; while, on the other hand, there are numerous instances of malnutri- 



202 RACHITIS. 

tion.and wasting without rachitis. Early diagnosis when the affection is of a 
mild type is necessarily difficult, but a watchful and painstaking physician 
will commonly detect the disease before it has run many weeks if he bear in 
mind its frequency and carefully examine the patient. 

If called to a suspected case, we should inquire into the history, and par- 
ticularly whether there have been signs of intestinal catarrh or innutrition. 
The gums should be inspected to ascertain whether there is backwardness in 
dentition, and the head to note its shape and size, whether it is elongated or 
whether it approximates the square shape, with broad forehead and large pro- 
tuberances. We should notice also the state of the fontanels and sutures, 
and whether softening and thinning of the cranial bones be present. The 
costochondral articulations and those of the wrist should also be carefully 
examined to ascertain if there is any enlargement, and the shape of the 
thorax, which begins to exhibit the rachitic deformity at an early stage of the 
disease, should likewise be noticed. We should also examine the child in 
reference to other less prominent signs, such as spinal curvature, abdominal 
protuberance, muscular weakness, and relaxation of ligaments (which pro- 
duce feeble and unsteady use of the limbs), perspirations upon the head and 
neck from slight excitement and during sleep, fretfulness, etc. If rachitis be 
present, certain of these signs will be observed. 

The late Dr. Parry called attention to the importance of making a differ- 
ential diagnosis between the pseudo-paraplegia of rachitis and true paraplegia, 
which is the prominent symptom of acute myelitis. The rachitic child, 
from muscular weakness and ligamentous relaxation, and from the soreness 
and tenderness common in this condition, may seldom use his legs — may sit 
or lie quietly at the age when healthy children, if awake, are constantly mov- 
ing their limbs. If we attempt to make him walk or stand, his legs may be 
so limp and powerless that they give way under his weight ; but this is a dif- 
ferent state from paralysis. In paralysis the fault is in the nervous system — 
usually in the nervous centres — whereas in rachitis it is in the muscles and 
ligaments. The rachitic child when sitting or lying down readily moves his 
legs if his feet be tickled or pinched, while the paralyzed limb responds to 
the irritation imperfectly. In acute myelitis the loss of muscular power 
is, with few exceptions, confined to the muscles of the lower extremities ; but 
in rachitis the muscular feebleness is more general, being noticeable in the 
arms as well as in the legs. Great relaxation of the ligaments is in most 
instances due to rachitis. It is especially noticeable in the ankle- and knee- 
joints, and is a diagnostic sign which should not be overlooked in the exam- 
ination of a suspected case of the disease. 

Prognosis of Rachitis. 

The prognosis of rickets is usually favorable, provided that no serious 
complication arises. Rachitis is not in itself fatal under ordinary circum- 
stances. If there be much lateral depression and narrowing of the thorax, 
the functions of the heart and lungs may be embarrassed, and if the patient 
have a severe hronchial catarrh or hrovcho-pneumonia. the condition becomes 
one of danger. Rachitic children seem to be especially liable to catarrhal 
attacks of the air-passages, and even a moderate catarrh with a deformed 
thorax may prevent proper decarbonization of the blood and cause lividity 
and dyspnoea. Therefore, now and then a rachitic child succumbs to an 
attack of inflammation of the respiratory apparatus which would not have 
been fatal if there had been no rachitic deformity. We have seen that in 
whatever way it may act to produce this form of spasm, rachitis is a cause of 
larymjisrtius stridulus. Occasionally spasm of the glottis is fatal, but cases 



TREATMENT OF RACHITIS. 203 

with such a termination are rare in America, though not infrequent in some 
European countries. 

Of the diseases of chiklhood which rachitic children tolerate badly, and 
which may prove fatal in consequence of rachitic bone-softening and deform- 
ity, pertussis should be mentioned. If this be severe w^hile the ribs are soft 
and yielding, and there be lateral depression of the thorax, the spasmodic 
cough produces great suifering and involves danger. Lividity, feeble action 
of the heart, pulmonary and cerebral congestion, and eclampsia may occur. 
Measles^ if it be attended by considerable bronchitis, and especially if it be 
complicated by broncho-pneumonia, is also one of the dangerous intercurrent 
diseases. The gravity of these inflammations of the respiratory apparatus is 
usually proportionate to the degree of recession of the ribs during inspiration. 
With these exceptions, and with that of risk to the married female who has 
deformity and stunted growth of the pelvic bones, the rachitic are not liable 
to any ulterior serious consequences. Minor deformities in mild cases not 
infrequently disappear in the subsequent growth of the skeleton. The older 
the child is when rachitis begins, the milder is ordinarily the form of the dis- 
ease, and the more speedy, consequently, the recovery, and the less the 
deformity. In the gravest cases the disease will almost always be found to 
have begun under the age of one year. 

Treatment of Rachitis. 

Since rachitis sometimes develops in the fa3tus, it is important in order to 
prevent this malady that the parentage be healthy. The pregnant woman 
should lead a quiet and regular life, with sufficient exercise to produce 
healthy digestion, but without too arduous work, and with regular meals and 
wholesome diet. By the observance of such rules foetal rachitis might prob- 
ably in most instances be prevented. Most cases of rachitis, however, com- 
mence in infancy, so that by proper management of the infant we may hope 
to prevent, and usually can prevent, its occurrence. 

The correct treatment of rachitis is apparent when we consider its charac- 
ter and the nature of its causes. The obvious indication is to restore healthy 
nutrition. This requires both hygienic and therapeutic measures. The apart- 
ment in which the child resides should be dry, airy, and plentifully supplied 
with light. He should be taken daily into the open air in order to invigorate 
his system, but in such a way as not to increase his suffering on account of 
his general tenderness. Residence in the country is far preferable to that in 
the city, because of the better hygienic conditions which it procures. The 
purer air, the better diet, and consequently the more robust development, 
gained by rural life are important advantages, to obtain which is abundantly 
worth pecuniary sacrifice when the children of a family are rachitic. 

The (lief in rachitis should receive particular attention, since indigestion 
and gastro-intestinal derangement sustain a causal relation to so many 
cases. Grood breast-milk ought, if possible, to be obtained until the child has 
reached the age of ten months, and if the mother's condition be such that she 
cannot furnish it, a wet-nurse should, if practicable, be employed. But after 
the age of six months additional nutriment is required. As a rule, the infant 
should be weaned at the age of twelve months, but longer nursing may be 
best under certain conditions, as the presence of hot weather, an' abundant 
supply of good breast-milk, and, on the part of the infant, feeble digestion 
and easily-deranged digestive organs. In case breast-milk cannot be obtained, 
cow's milk, properly diluted, according to the age, with Avater or with a fari- 
naceous solution, is the best substitute. The reader is referred to the chapter 
relating to the diet of infancy for full particulars relating to infant feeding. 



204 RACHITIS. 

The- milk should be sterilized by steaming in the manner mentioned in the 
chapter on artificial feeding, and for infants with feeble digestion it may be 
well to peptonize the milk. A properly-prepared farinaceous substance mixed 
with the milk has not only nutritive properties, but by mechanically sepa- 
rating the particles of casein it tends to prevent the formation of curds in the 
stomach. But as young infants digest starch with difficulty, it is well, I 
think, to employ a flour, as barley, wheat, or oatmeal, in which the starch is 
to a great extent converted into dextrin by the prolonged action of heat or 
into grape-sugar by the action of the diastase of malt, as recommended by 
Liebig. This flour, made into a gruel and mixed with sterilized or peptonized 
milk, is a suitable food for rachitic infants. 

Meat soups, properly prepared according to the age, are useful additions 
to the diet. I have elsewhere stated that in one of the institutions of New 
York rachitis from being common was made to disappear almost entirely by 
allowing a more generous diet, a part of which was the daily use of a little 
beef tea. I have employed, with apparently good results, beef tea prepared 
as follows : x\dd half a pound of finely-hashed beef to one pint of cold water, 
mix with ten drops of dilute muriatic acid, allow it to stand cold with fre- 
quent stirring half an hour, then place it upon the table in a pail or large 
pan of boiling water, so as to heat it without coagulating the albumen. In 
an hour it is ready for use. The peptonized beef of the shops is also a 
useful preparation. 

3Iedicines which improve the general health are all more or less beneficial 
in the treatment of rachitis, but lime and cod-liver oil are especially indicated. 
The following formula will be found useful in most cases : 

R- Olei morrhuse, f^iv; 

Aq. calcis, 
Syr. calcis lactophosphatis, dd.f^'i}. Misce. 

Of this, one teaspoonful should be given four or five times daily to an 
infant of one year. This combination agrees with the digestive function, and 
is readily taken by most infants. Cod-liver oil, while it improves the general 
nutrition, is especially useful in rachitis. 

Care should be taken to prevent deformities while the bones are soft and 
yielding. The patient should not be encouraged to stand or use the limbs 
until they become firmer. He should lie upon an even and soft mattress and 
should be taken into the open air in a carriage. A uniform support of body 
and limbs is requisite in order to prevent curvature. 

In craniotabes the pillows should be soft, and care should be taken that 
the yielding parts of the cranium should not be unduly pressed upon. The 
perspirations may be relieved by sponging with vinegar and water. The 
infant should be regularly bathed in water a little cooler than the body, and 
rock salt may be added to the bath. The proper treatment of laryngismus 
stridulus, which so frequently complicates rachitis, is described in our remarks 
upon that disease. Constipation, common in the rachitic, should be treated 
by simple enemata, except so far as it can be relieved by change in the diet. 
When curvatures are unavoidable, orthopaedic treatment will subsequently 
be required. 

Such is an outline of the treatment which rachitis ordinarily requires, but 
other medicinal agents may be found useful for their general tonic action or 
by supplying lime-salts to the system ; among which may be mentioned the 
compound syrup of the phosphates, the citrate of iron and quinia, wine of 
iron, the various preparations of cinchona, columbo, etc. Flieschmann 
recommends the fluorine compounds in order to increase and harden the 



CAUSES. 205 

enamel of the teeth, employing for the purpose the tooth pastille of EhrhaHt 
or Hunter, which contains the fluoride of potassium. 



CHAPTER II. 

SCROFULA. 

The term scrofula (scro/a, a pig, from the resemblance of the enlarged 
cervical glands of a scrofulous individual to a swine's neck) is applied to a 
diathesis which is characterized by increased vulnerability of the tissues. 
The nutritive process of the tissues is readily disturbed even by trifling irri- 
tants or agencies in those who have this diathesis, and therefore the scrofulous 
are prone to inflammations of various parts. Inflammations, which can prop- 
erly be considered as dependent upon this diathesis or as occurring under its 
influence, are for the most part subacute or chronic, and they differ from 
ordinary inflammations in the fact of a greater cell-formation and greater 
liability to cheesy degeneration of inflammatory products, so that return to 
the healthy state by absorption is slow or impossible. 3Ioreover, this diathesis, 
while it gives rise to certain inflammations which do not occur or are rare in 
other states of the system, and which all physicians at once recognize as 
scrofulous, often modifies those common inflammations to which all persons, 
whether scrofulous or non-scrofulous, are liable, as coryza and bronchitis, 
rendering them more protracted and less amenable to ordinary treatment. 

Scrofula is a disease chiefly of infancy and childhood. Manhood, espe- 
cially the first years of it, is not entirely exempt, but scrofulous manifesta- 
tions after the age of twenty years are feeble and infrequent, disappearing 
entirely as the individual advances toward middle life. The diathesis is most 
active prior to the age of ten years. 

Causes. — Scrofula is congenital or acquired. Parents who had scrofulous 
symptoms in early life or who are in a state of decided cachexia, as from can- 
cer, syphilis, intermittent fever, or tuberculosis, are likely to beget scrofulous 
children. Insufficient nourishment of the mother during a considerable part 
of her gestation, and advanced age, and therefore feebleness, of the father, 
are occasional causes. Near blood-relationship of the parents is also a recog- 
nized cause, and to this has been attributed the scrofula of royal families. 
Children whose father and mother are first cousins are, according to my 
observations, likely to be scrofulous. 

Again, those born with sound constitutions may acquire scrofula through 
antihygienic influences in the first years of life. Among the poor of New 
York we often observe one child in a family who presents scrofulous symp- 
toms, while the rest of the children are well, and in many cases we are able 
to trace back the diathesis to some depressing cause or causes which were 
sufficient to efl"ect the peculiar change in the molecular condition of the tissues 
which constitues this disease. Obviously, the causes of acquired scrofula are 
quite numerous. In the infant it is sometimes produced by insufficiency or poor 
quality of the breast-milk, or the use of artificial food during the period when 
breast-milk is required. Too protracted nursing at the breast also, especially 
if artificial food be almost wholly withheld, may cause it ; as may also, in 
those who have been weaned, the continued use of a diet which is deficient 
in nutritive properties. 

Residence in damp, dark, and filthy apartments or streets may also pro- 



206 SCROFULA. 

duce it. Hence one reason of its frequent occurrence among the city poor. 
Residence in a small, crowded, and imperfectly ventilated apartment has been 
known to cause it, even with personal cleanliness and a diet sufficiently 
nutritive. 

Scrofula may also be caused, in those previously robust and of sound con- 
stitution, by disease of an exhausting nature. The eruptive fevers, as small- 
pox, measles, and scarlet fever, if severe, occasionally produce this result, or 
they render active the diathesis, which had hitherto been latent. In this city, 
where chronic entero-colitis of infancy is common, I have sometimes been able 
to trace the diathesis to the cachectic state and the impaired nutrition which 
it causes. 

The theory has recently been promulgated that scrofula has a specific 
principle, and that this is a modified form of the tubercle bacillus. This 
theory receives some support from the fact that scrofulous glands sometimes 
contain the tubercular bacillus, and scrofula in many instances precedes tuber- 
culosis. Van Merris considers the scrofulous inflammation as a local tubercu- 
losis, and Grancher describes scrofula as a local curable tuberculosis. On the 
other hand, Dr. Jacobi regards the tubercle bacillus in a scrofulous disease as 
an " accidental invasion," and Lartigues calls attention to the fact that the 
tubercle bacillus cannot be discovered in most instances in the lesions of 
scrofula. Alexander also states that wherever we can trace the cause of 
scrofula, it seems to be distinct from any probable microbic agency (^Annual 
of the Univer. Med. Sci., vol. iv., 1889). Noeldechen states that the close 
relationship of tuberculosis to scrofula arises from the fact that scrofulous 
ailments afford the most favorable soil for the development of the tubercle 
bacillus (^Deutsche med. Zeit..^ 1887). Rabl also mentions the fact that the 
tubercle bacillus is often not present in scrofulous glands. He tabulates 
1000 cases of scrofula, as regards their causation, as follows: 79 had scrofu- 
lous parents, 446 had tuberculous parents, 356 lived in damp dwellings, 25 
were subjected to other bad hygienic surroundings, 69 could be ascribed to 
acute infectious diseases, 14 to vaccination, 7 to decrepitude, and 4 to con- 
sanguinity of parents ( Wien. med. Zeit., 1887). 

Scrofula, as we have seen, results from a variety of depressing agencies 
affecting the system in different ways, with the general result of impairing its 
vigor and lowering its tone. The theory seems improbable that these many 
and distinct agencies cause the phenomena of scrofula through the action of 
a microbe peculiar to this disease. 

The primary scrofulous ailments by which the diathesis is manifested 
occur for the most part upon one of the free surfaces — namely, upon some 
part of the skin or mucous membrane. Certain writers attribute this to the 
fact that these parts are most exposed to the action of noxious agencies. The 
lymphatics lying in the inflamed area take up the altered lymph and carry it 
to the adjacent lymphatic glands, which become irritated and undergo hyper- 
plasia, and perhaps ultimately suppuration. This is, in a large proportion 
of cases, the beginning of scrofulous ailments. Nevertheless, in not a few 
instances the first manifestations are in deep-seated and covered parts, as when 
scrofulous periostitis or osteitis occurs without any peripheral lesion. 

Rabl expresses the opinion that in certain cases scrofula results from 
syphilis in the parent or grandparent. He believes that syphilis in the parent 
causes scrofula in the child by diminishing the power of resistance to the 
causes which produce the latter affection. He thinks that in this manner 
parental syphilis gives rise in some children to symptoms identical with those 
of scrofula, while in other children it gives rise to syphilitic symptoms. The 
author's observations in this particular correspond with those of Rabl. 

Anatomical Characters. — There are no ascertained anatomical changes 



ANATOMICAL CHARACTERS. 207 

in the blood which are peculiar to scrofula. As long as the appetite and gen- 
eral health remain good and the local affections have not occurred, the com- 
position of this fluid is, so far as known, unaltered. In the cachexia which is 
present when the general health is impaired the blood becomes impoverished, 
the red corpuscles lose a portion of their coloring matter, and the watery ele- 
ment predominates. 

The question arises whether the glandular hyperplasia of scrofula produces 
an excess of white corpuscles in the blood. Virchow says : " During the 
progress of an attack of scrofula, in which, if the disease run a somewhat 
unfavorable course, the glands are destroyed by ulceration or cheesy thicken- 
ing, calcification, etc., an increased introduction of corpuscles into the blood 
can only take place as long as the irritated gland is still, in some degree, 
capable of performing its functions or still continues to exist; as soon, how- 
ever, as the glands are withered or destroyed the formation of lymph-cells 
likewise ceases, and with it the leucocytosis. In all cases, on the other hand, 
in which a more acute form of disturbance prevails, connected with inflam- 
matory tumefaction of the gland, an increase of the colorless corpuscles 
always takes place in the blood" {CelM.. Pathol.). Although the glandular 
hyperplasia occurring in scrofula increases the number of white corpuscles in 
the blood, scrofula cannot be regarded as sustaining any causal relation to 
that great and constant increase of white corpuscles which characterizes the 
disease leuksemia ; for this disease, as remarked by Niemeyer, does not occur 
in childhood, when the scrofulous diathesis is active, but in manhood, when it 
has ceased to exist or has become latent. 

Strumous inflammations of the cutaneous and mucous surfaces, which we 
have seen are the initial lesions in a large proportion of scrofulous cases, do 
not present any peculiar anatomical elements. Some of them are attended 
by an abundant formation of cells and by dense infiltration of the inflamed 
tissues ; but inflammations which do not depend" on the strumous diathesis 
have the same anatomical elements. The most marked differences between 
the strumous and non-strumous inflammations are found in their origin, 
amount of cell-formation and inflammatory exudate, and duration. 

The swelling of the lymphatic glands which is so common in the neigh- 
borhood of scrofulous inflammations, and is produced by the lodgment in the 
glands of irritating or noxious products of the inflammation taken up by the 
lymphatics and conveyed to the glands, is due to hyperplasia of the lymph- 
cells, with comparatively little or no increase of the stroma. Thus, hyper- 
plasia of the cervical glands is common, resulting from eczema of the scalp or 
face, or from otitis or any of the forms of stomatitis; and so pharyngitis often 
gives rise to hyperplasia of the tonsils, which are lymphatic glands. The 
scrofulous nature of the glandular enlargement is apparent from the fact that 
it continues long after the primary inflammation which gave rise to it has 
abated. Lymphatic glands sometimes enlarge in those who are not scrofulous, 
but the tumefaction is commonly less in degree, and in most instances it soon ' 
abates when the excitinii; cause is removed. 

The glands which commonly undergo scrofulous enlargement are the cer- 
vical, inguinal, bronchial, and mesenteric ; but in those who are decidedly 
scrofulous the glands in the vicinity of any protracted inflammation are very 
prone to hyperplasia. Thus I have seen enlarged and cheesy glands in the 
vicinity of scrofulous osteitis or periostitis. 

Under favorable circumstances the glandular enlargement abates after a 
short time by liquefaction and absorption of the redundant cells. But the 
products of hyperplastic or inflammatory action in the scrofulous individual 
are very liable to undergo cheesy degeneration, and the close causal rela- 
tion of this cheesy substance with tubercles is now admitted. If resolution 



208 SCROFULA. 

do not soon occur in the gland, it begins to undergo cheesy degeneration. 
It becomes firm and inelastic, its nutrient vessels narrowed and compressed, 
so that circulation through it ceases, and its cells, losing their liquid and 
vitality, shrivel away. This necrobiotic process appears in points in the 
gland w^hich enlarge and unite, till finally the whole gland becomes a dead 
mass, with shrivelled elements of a whitish appearance, like cheese, the 
resemblance to which has suggested the name by which the degeneration 
is known. 

In certain patients cheesy glands act as an irritant like inorganic matter, 
producing suppurative inflammation, and their subsequent history is that of 
an abscess. Purulent matter mixed with the cheesy debris escapes by ulcera- 
tion upon the nearest surface, and scrofulous ulcers result which slowly heal, 
leaving permanent cicatrices ; calcification of a cheesy gland occurs in excep- 
tional instances. 

The cervical lymphatic glands in the scrofulous child, having under- 
gone hyperplasia of their cellular elements, not infrequently continue pain- 
less and indolent for a considerable time, producing, according to their size, 
an unsightly appearance without undergoing cheesy degeneration. Finally, 
one or more become inflamed, and the broken-down gland substance softens 
and is expelled, mixed with pus, through an ulcerated opening in the skin. 

In order to complete the description of the anatomical character of scrof- 
ula, it would be necessary to describe the various inflammations to which the 
diathesis gives rise. Those which are most common and important occur in 
the skin, mucous membrane, connective tissue, the joints, the bones with their 
periosteal covering, and the eye and ear. Eczema and coryza are also very 
common scrofulous ailments. Phlyctenular keratitis with great intolerance 
of light, otitis externa, causing protracted otorrhoea, or media and interna, 
causing deep-seated pain, with impairment or loss of hearing, off'ensive puru- 
lent discharge, and, in the gravest cases, caries of the mastoid cells or caries 
extending along the petrous portion of the temporal bone even to the brain, 
causing meningitis and death, are not uncommon manifestations of scrofula 
in the families of the city poor. Strumous cellulitis, occurring independently 
of the glandular afi'ection and quickly ending in suppuration, is also common. 
The term co/d is applied to the abscess when the local symptoms are slight 
and there is but little heat of the parts. In young children the common seat 
of these abscesses is directly under the skin, so that if subcutaneous cellulitis 
running into an abscess occur in a young child, he probably has the strumous 
diathesis. 

The osseous system is very prone to inflammation in the scrofulous. 
Periostitis, osteitis, and arthritis, rare in those with healthy constitutions, 
are common in the scrofulous, in whom they result even from very slight 
injuries, and sometimes without the recollection of an injury, and apparently 
from the direct influence of the diathesis. These inflammations are more 
common in the lower extremities than in the upper. Periostitis often occurs 
in scrofulous children without osteitis, when its usual seat is upon the shafts 
of the long bones, and it also accompanies inflammations of the bone, as 
pleurisy accompanies pneumonia. The osseous inflammations of strumous 
patients are of two kinds : first, the destructive, producing caries with sup- 
puration or necrosis ; and, secondly, the so-called fungous^ in which there is 
proliferation of tissue, as in white swelling. Often both these processes 
coexist, granulations and new tissue springing up while the carious or 
necrotic process is extending. 

Dactylitis is in most instances, when occurring in young infants, a syph- 
ilitic aff"ection, but in children of one year or more, in whom no marked syph- 
ilitic symptoms have previously occurred, it originates from the strumous 



SYMPTOMS. 209 

cachexia, as in the following case : Charles R , aged twenty months, was 

admitted into the New York Infant Asylum in 1876. He had always been 
pallid and had a strumous aspect. A physician acquainted with his parent- 
age states positively that he is free from syphilitic taint, but when a few 
months old he had a mild form of coryza, which gradually abated under anti- 
strumous treatment. At the age of five months he had purpura hsemorrhagica 



Fig. 22. 



P\ 







of a severe form, but apparently not accompanied by hemorrhage- from any 
of the mucous surfaces. The patches of extravasated blood were quite 
numerous and large over the trunk and limbs, and it was nearly three 
months before they entirely disappeared. A few months subsequently he 
began to have offensive otorrhoea on one side, which did not entirely cease. 
In December, 1876, at the age of eighteen months, well-marked dactylitis 
was first observed, involving the first phalanx of the left middle finger. The 
swelling was somewhat tender, and the skin which covered it had a slightly 
reddish or pinkish tinge, indicating the inflammatory nature of the malady. 
Neither joint at the extremity of the phalanx was involved, so that the 
movements were unimpaired. The dactylitis increased somewhat after it 
was first discovered, and then began to decline under treatment with cod- 
liver oil and syrup of iodide of iron. The accompanying woodcut repre- 
sents the outlines, obtained by tracing the hand of the infant when pressed 
on paper. 

Symptoms. — The scrofulous diathesis is exhibited by certain physical 
signs which are present in infancy, but are more manifest in childhood. In 
one class of strumous children they are as follows : Form tall and slender ; 
quickness of movement and perception ; intelligence good ; skin thin and 
semi-transparent, through which the superficial veins are distinctly ' seen ; 
features delicate ; cheeks habitually pallid or florid, and flushed by slight 
excitement ; eyes bright, with bluish conjunctiva ; muscles and bones slen- 
der in proportion to their length. Those children who present these pecu- 
liarities are said to have the erethitic form of the diathesis. 

14 



210 SCROFULA. 

Others have what has been designated the torpid scrofulous habit, which 
is characterized by softness and flabbiness of the flesh, distended abdomen, 
large head, broad face, slow, languid movements, and an over-production 
of fat in the subcutaneous connective tissue in certain situations, especially 
the nose and upper lip. Though typical cases can be readily referred to 
one or the other of these forms, there are many which are intermediate. 

One of the earliest of the scrofulous manifestations is subcutaneous 
cellulitis, alluded to above, giving rise to abscesses, commonly not large, 
with little surrounding induration, little pain, tenderness, and heat, and slow 
in discharging; in a word, indolent. The most frequent seat of these 
abscesses is upon the extremities, but they may occur upon the scalp or 
elsewhere. They gradually heal when the pus escapes, their site being indi- 
,cated for a considerable time by the depression and reddish discoloration 
of the skin. Ordinarily, these abscesses do no harm apart from the reduction 
of the general health which they effect, but, when occurring in localities 
where the connective tissue lies upon the periosteum, as upon the fingers, 
periostitis may result, with destruction of the surface of the bone. Again, 
thrombi may occur in the vessels of the inflamed part, giving rise to emboli, 
embolismal pneumonia, and death. Specimens from such a case were pre- 
sented by me to the New York Pathologicat Society in 1868. 

The scrofulous afi"ections of the skin often also occur at an early age, 
even before dentition. They are more frequent in infancy than in child- 
hood. The most common are eczema and impetigo, and, of rare occur- 
rence, ecthyma and lupus. But all these may occur in those who are 
not strumous or who do not present the characteristics of the strumous 
diathesis. 

Scrofulous affections of the mucous surfaces are scarcely less frequent 
than those of the skin. They present the ordinary features of mucous 
inflammations of a subacute and chronic character. 

Sometimes they occur without obvious exciting cause ; in other cases 
there is a cause of this kind, such as exposure to cold ; but the inflamma- 
tion, once established, continues on account of the diathesis. It is often 
doubtful whether inflammations in strumous subjects be of such a character 
that it is proper to designate them strumous, especially if they occur upon 
such surfaces as are frequently the seat of ordinary inflammation. If the 
child have heretofore presented symptoms of scrofula, if the inflammation 
be subacute, and there be no apparent cause to originate or sustain it apart 
from the diathesis, it is probably of a strumous character. The diagnosis 
is rendered more certain by observing the effect of antistrumous remedies. 
The most frequent of these scrofulous inflammations of mucous surfaces 
are coryza, tracheo-bronchitis, and conjunctivitis. More rarely, stomatitis, 
pharyngitis, vaginitis, and, according to some, entero-colitis, are of a stru- 
mous character. Coryza gives rise to snuffling respiration, the formation 
of crusts around and within the nares, and excoriation of the upper lip. 
The tracheo-bronchitis is attended by thickening of the mucous membrane, 
increased production of mucous and epithelial cells, and a loud tracheal rale 
accompanying each inspiration. 

Strumous inflammation of the mucous membrane of the trachea and 
bronchial tubes is not a very infrequent disease in this city. It sometimes 
originates in a simple inflammation from cold or the tracheo-bronchitis of 
measles or pertussis, and it may continue, with its rales, cough, and 
scanty expectoration, for months, unless relieved by a proper course of 
treatment. 

Among the most common of the strumous affections are inflammation of 
the eyelid, designated psorophthalmia, and that of the eye itself. The 



PEOGyOSIS. 211 

former is characterized by redness and thickening of the lids, detachment of 
the eyelashes, and inflammation and altered secretion of the '" Meibomian 
glands :" the latter — to wit, strumous ophthalmia — by pain, lachrymation. 
photophobia, and a moderate degree of hyper^emia of the affected organ. 
One of the most common serious results of strumous conjunctivitis and kera- 
titis is the formation of phlyctenulae and ulcers on the margin of the con- 
junctiva and upon the cornea, fed by newly-formed vessels. If not con- 
trolled by proper treatment they may result in opacities more or less perma- 
nent, or possibly, worse still, in perforation, with its consequent ill effects. 

Inflammations of the external and middle ear have their origin very gen- 
erally in the strumous diathesis. Occasionally there is an exciting cause of 
the otitis, as an injury or severe constitutional disease, like scarlet fever. 
Protracted otitis, whether external or internal, and especially that form of 
it which leads to ulceration, destruction of the ossicles, and caries of the 
petrous portion of the temporal bone, it is proper in a large proportion of 
cases to regard and treat as strumous. 

The stubbornness and frequent disastrous consequences of scrofulous 
inflammation of the bones are well known. Nearly every bone, as well as its 
periosteum, is liable to this form of inflammation, but some are more fre- 
quently affected than others. ' Inflammation of the bone may terminate by 
resolution, by the formation of an abscess, or (and frequently) by carious or 
necrotic destruction of the bone itself.- Xecrosis most frequently occurs in 
the shafts of the long bones ; caries in the spongy extremities of these bones 
and in the spongy portions of the short bones. If abscesses form, the pus 
may finally escape from the system by a tedious ulcerative process, or, 
retained, may undergo chees}^ degeneration. Scrofulous arthritis, if early 
detected and properly treated, may resolve, leaving no ill effect ; if other- 
wise, suppuration, ulceration, cartilaginous and osseous, and ankylosis often 
occur. 

Scrofulous children are perhaps no more liable to inflammation of the 
internal organs than other children, but the inflammatory products are more 
liable to cheesy degeneration, and the prognosis is therefore less favorable. 
The most frequent of these inflammations and the one of chief interest is 
pneumonia. Catarrhal pneumonia, so frequent in early life, whether primary 
or secondary, in connection with measles, pertussis, etc., is a disease often 
involving grave consequences in those who are decidedly scrofulous, since, 
instead of resolving, the affected lung-tissue presents a strong tendency to 
caseous degeneration, ending in tuberculosis of the lungs and death. I have 
most frequently noticed cheesy pneumonia during extensive epidemics of 
measles as a complication or sequel of this disease. It may occur in those 
who are not scrofulous if the vital powers be greatly reduced, but it is so 
much more common in the scrofulous that some recent writers have desig- 
nated this form of inflammation by the term of scrofulous instead of cheesy 
pneumonia. From the fact, however, of its sometimes occurring in the non- 
scrofulous, the term cheesy or caseous — especiall3^ too, as it expresses the 
anatomical state — seems more appropriate. 

The caseous substance which results from degeneration of the products 
of scrofulous inflammations affords a nidus in which the tubercle bacillus 
frequently obtains lodgment and conditions favorable for its propagation. 
Hence the close etiological relations of scrofula or scrofulous inflammations 
to tuberculosis. 

Prognosis. — As scrofula may be acquired through antihygienic influ- 
ences, so it may disappear or become latent through influences of an opposite 
character. Therefore the manifestations of scrofula may be limited to a brief 
period, or they may occur at intervals through the whole of childhood and 



212 , SCROFULA. 

the first years of youth. When the diathesis is inherited and fostered by 
unfavorable circumstances, the scrofulous affections appear earliest, are most 
varied and severe, and continue longest. 

In most cases, with proper treatment, the prognosis is good, but the dan- 
ger to life depends on the nature and extent of the scrofulous inflammation. 
The most common unfavorable result is the occurrence of pulmonary or gen- 
eral tuberculosis, the caseous substance, as we have said, affording a favorable 
nidus for the development and propagation of the tubercle bacillus. This is 
the usual result in cheesy pneumonia. The next most common cause of 
death, either directly or indirectly, is inflammation of the osseous system. 
Many deaths occur from inflammation of the vertebrae or of the hip or knee- 
joint when it has been allowed to continue a considerable time without proper 
treatment. Protracted suppurative inflammation of the bones is liable to 
produce amyloid degeneration of organs, which is permanent and likely to 
prove fatal, or death may occur from exhaustion, with or without tubercu- 
losis. Among the city poor meningitis is not very uncommon, consequent 
on long-continued otitis media and caries of the petrous portion of the tem- 
poral bone. Permanent impairment of sight and hearing often results from 
neglected strumous ophthalmia and otitis. 

At puberty the strumous affections gradually become less frequent, and 
they finally disappear in advancing age. Among the most robust adults are 
some who in early life presented indubitable symptoms of the strumous 
diathesis. 

Treatment. — Prophylactic. — Measures designed to prevent scrofula are 
impossible without the co-operation of willing and intelligent parents. It is 
obvious that the prevention of congenital scrofula requires the treatment of 
disease or impaired health in the parent. If parents should be taught or 
should remember that good health in themselves is the necessary condition of 
the inheritance of a sound constitution in the child, and would adopt such 
therapeutic and regimenal measures as would procure this, the number of 
cases of inherited scrofula would be materially reduced. 

As the first years of life are very important, both for correcting the 
diathesis when inherited and for preventing its development in those of sound 
constitution, care should be taken that the regimen of the child be such that 
it does not cause deterioration of the general health. The nursing infant, 
if the mother be in poor health, should be provided with a healthy wet-nurse, 
for in young children the diathesis may be acquired solely by the use of food 
that is scanty or of poor quality. Those old enough to be weaned should 
have plain and nutritious diet, with a proper admixture of animal food. More 
or less outdoor exercise and residence in a salubrious locality, with sufficient 
air and sunlight, are also requisite. 

Curatire. — Since scrofula originates in a state of weakness existing in the 
parent in the congenital, and in the child in the acquired, form of the disease, 
and is characterized by feeble resistance of the tissues to irritating agents, 
the inference is reasonable that all tonics have, to a certain extent, an anti- 
scrofulous effect upon the system. ^ The ordinary vegetable tonics, and some- 
times the ferruginous, are indeed useful in the treatment of scrofula. 
Employed in connection with proper regimenal measures, they are sufficient, 
in many cases, to remove, the diathesis after a time or render it latent. 
Besides these medicinal agents, which tend to correct the scrofulous diathesis 
by their general tonic effect, there are certain others which experience has 
shown to be beneficial in the treatment of scrofulous affections, and which 
are therefore largely used. One of these is cod-liver oil, which contains iodine 
among its many ingredients. 

Cod-liver oil is useless or nearly so in the torpid form of the diathesis, 



TREATMENT. 213 

which is characterized by an increased deposit of fat in the subcutaneous 
connective tissue, slow circulation, and sluggish muscular movements. On 
the other hand, in the treatment of the erethitic form it possesses real value. 
Its protracted use in such cases does so modify the molecular condition of 
the tissues that they are less liable to inflammation, and the diathesis is there- 
fore rendered milder or removed. From one to three teaspoonfuls, according 
to the age, should be given three times daily. While we frequently expe- 
rience so much difficulty in administering it to adults affected with tubercu- 
losis, and sometimes find it necessary to discontinue its use on account of its 
nauseating efl'ect, scrofulous children rarely refuse to take it, and it does not 
seem to diminish their appetite. 

Iodine is justly celebrated as a remedy in the treatment of scrofulous mal- 
adies, but it is a question whether it has not been overrated as a remedy for 
the diathesis itself. Iodine employed internally is especially serviceable in 
glandular hyperplasia and in scrofulous thickening and induration of the con- 
nective tissue and periosteum. In general, it should not be administered to 
children in its isolated state, on account of its irritating properties, but one 
of its compounds should be employed. The compounds which are chiefly 
prescribed in the treatment of scrofula are the iodides of starch, iron, potas- 
sium, and sodium. If, as is frequently the case, the patient be pallid and his 
appetite poor, the iodide of iron should be preferred ; if not in this cachectic 
state the iodide of starch may be used. Pharmaceutists prepare syrups of 
both these iodides, so that they can be readily administered to the youngest 
child. The iodide of starch may be administered by dropping from one to 
five drops of the officinal tincture of iodine on a little powdered starch and 
giving it in syrup. These iodides are preferable to the iodides of potassium 
and sodium for internal administration to children, since they are not irritating 
to the mucous membrane and the iodine is readily set free. Prof. Dalton 
has, indeed, demonstrated that the iodide of starch is decomposed in most of 
the liquids of the body and the iodine liberated. 

In New York City a large proportion of the scrofulous children are cachec- 
tic and need iron, and the iodide of iron is more frequently employed, and 
with good results, than any other iodine compound. The syrup of the iodide 
of iron, which is readily absorbed, should be given in one- to two-drop doses 
three times daily to a child of six months, and one additional drop be added 
for each additional year. i\.mong the vaunted remedies of scrofula are phos- 
phoric acid and the phosphate of lime. I have not employed these agents 
without at the same time using other remedies, and cannot say, therefore, to 
what extent they have been curative in my practice. Probably there is no 
better combination of remedies for the strumous diathesis than the following, 
which is now used in some of the institutions of New York, and which we 
have already recommended in the treatment of rachitis : 

R. 01. morrhuse, 2 parts; 

Syr. calcis lactophosphat., 1 part ; 

Aquse calcis, 1 part. Misce. 

Dose : One teaspoonful to a dessertspoonful three or four times daily. The 
syrup of the iodide of iron should be given at the same time in three daily 
doses, but not mixed with the above preparation of oil and lime, as a double 
decomposition occurs from the admixture. 

The internal use of mercury as an antidote for scrofula is now generally 
discarded. Unless, perhaps, in those cases in which the diathesis is imme- 
diately dependent on syphilis, its use for this purpose, from what we know 
of its therapeutic eff'ects, would probably be more injurious than beneficial. 



214 SCROFULA. 

Among the medicines whicli have from time to time been employed for the 
cure of scrofula, some of which have had considerable reputation, but have 
nearly fallen into disuse, are walnut-leaves, sarsaparilla, elecampane, conium, 
digitalis, horseradish, compounds of silver, gold, arsenic, baryta, and bromine. 
It is probable that none of these has any effect on scrofula or scrofulous ail- 
ments except such as improve the appetite and general health, as horseradish. 

The same hygienic measures are required in the treatment of scrofula 
as are employed in the prophylaxis of it. The nursing infant should 
have healthy breast-milk, and if its mother belong to a tubercular or scrof- 
ulous family or be feeble, a healthy wet-nurse should be employed, or it 
should be sent to the country, where suitable cow's milk as well as pure air 
can be obtained. The expressed juice of beef slightly boiled, the peptonized 
beef or beef tea prepared as recommended for rachitic infants, given several 
times daily in small quantity to infants, aid materially in restoring a better 
nutrition of the tissues. Obviously, similar care is necessary in the selection 
and preparation of the food of children who have passed beyond the period 
of infancy. While the diet should be highly nutritious, it should be plain 
and easily digested, and given at sufficient intervals, so as not to overtax 
digestion. The cow's milk employed should be of the best quality, and for 
young children it may be best to peptonize it. 

Fresh air, outdoor exercise, daily bathing, personal and domiciliary clean- 
liness, are very necessary for the successful treatment of the diathesis. Since 
scrofula is comparatively infrequent in farming sections, scrofulous families 
are greatly benefited by farm-life, with all the accessories to health w^hich 
pertain to it. The use of sea-air and sea-bathing has, according to the testi- 
mony of several observers, been very efficacious. Dr. F. P. Henry states 
that no other remedial measure is so efficacious as these (An7ii(al of Univer. 
Med. Sci, 1889). Dr. Valcourt, who is in charge of the Maritime Hospital 
at Cannes, where scrofulous children receive daily sea-baths during a consider- 
able part of the year, read an interesting paper in commendation of its use 
before the Paediatric Section of the Ninth International Medical Congress 
in 1887- Alexander quotes the statistics prepared by Cazin, which show 
that the mortality of scrofulous children is much less in the hospital at Barek, 
where sea-bathing is employed, than in two Parisian hospitals (Ltvei-p. Medico- 
Cklr. Jour., 1888.) 

The local scrofulous ailments require additional and special treatment. 
Those located on the cutaneous and mucous surfaces are less dangerous, as 
a rule, than the deeper-seated inflammations ; still, they should be promptly 
treated, not only for the inconvenience and annoyance which they cause, but 
because they may give rise to hyperplasia of the neighboring glands, as we 
have stated elsewhere. Thus, pharyngitis may cause a peripharyngeal ade- 
nitis and abscess, and a bronchitis may cause adenitis of the bronchial glands, 
with the probability of their cheesy degeneration. The so-called bronchial 
phthisis is believed to result, in a large proportion of cases, from a strumous 
bronchitis which has been allowed to continue uncontrolled by medicine, and 
a similar state of the mesenteric glands may result from intestinal catarrh. 
Inflammation of the skin or mucous surface occurring in the strumous requires 
the continued use of antistrumous remedies, conjoined with such treatment, 
designed to act locally, as is appropriate for the case. 

It is the common practice to treat the enlarged glands of struma by daily 
applications over them of the stronger iodine preparations. This treatment 
does not cause absorption of the redundant gland-substance. It causes pro- 
liferation of the epidermic cells, and quickens the cell-change in the adjacent 
gland and accelerates suppurative inflammation. I once produced accidentally 
such an amount of vesication over an enlarged, hard, and apparently indo- 



TREATMENT. 215 

lent gland in an infant of fourteen months that I was very anxious lest a 
sore should result which would heal with difficulty, and yet, instead of dis- 
persion of the glandular swelling, the pathological processes were so promoted 
that suppuration and discharge of pus occurred by the time that the cuticle 
had re-formed. 

We know no better substance for the local treatment of strumous adenitis 
than iodine, and it should be applied, in my opinion, in such a manner that 
it is absorbed with the least possible irritation of the gland. The following 
will be found useful ointments and solutions for the treatment of these cases : 

R. Potas. iodidi, .^j ; 

Ung. stramonii, 5J. 

To be rubbed over the gland several times daily. It should not be applied as 
a plaster, since it is too irritating and will vesicate. I have known a gland- 
ular swelling which had continued about three months to disappear in three 
weeks under its use in connection with internal remedies. Lanolin may be 
employed in place of the stramonium ointment, inasmuch as it is believed to 
be more readily absorbed than most oleaginous substances. Another useful 
iodine mixture for these cases is the following : 

R. Liq. iodinii composita, 

Glycerinse, equal parts. 

To be applied as an inunction. Glycerin renders the skin soft and in a state 
favorable for absorption. 

In The Medical Press am? Circular for August 3, 1870, J. Waring Curran 
states that he has used with great success what he designates a new iodine 
paint, consisting of half an ounce of iodine, the same quantity of iodide of 
ammonium, twenty ounces of rectified spirits, and four ounces of glycerin. 

Mercurial ointments have been recommended by writers of reputation for 
the treatment of these glands. I have employed them and known them to be 
employed, but cannot say that I have ever observed any benefit whatever 
from their use. In the children's class at the Out-door Department at Bel- 
levue we have discarded them entirely for this purpose, although both the 
citrine and white precipitate ointments, diluted with an equal quantity of 
lard, have been used with apparent benefit for chronic coryza of a strumous 
nature, and also occasionally for external otitis of the same nature. 

In a paper read at the meeting of the British Medical Association in 1870 
by Mr. Jordan, the writer recommends, as attended with success, vesication, 
not over the gland, but at a little distance from it — as, for example, behind 
the neck — for treatment of the cervical glands. But a mode of treatment 
which seems so unlikely to be beneficial requires stronger proof of its utility 
than has yet been presented. 

The application of cold over an inflamed lymphatic gland and the adjacent 
inflamed connective tissue is a useful adjuvant to the treatment in many cases 
at an early stage. A small India-rubber bag containing ice, or muslin fre- 
quently wrung out of ice-water and applied over the inflamed parts, contracts 
the vessels, diminishes the activity of the morbid process going on under- 
neath, and aids materially in the resolution. When the gland becomes so 
actively inflamed or the inflammation so advanced that redness of the skin 
occurs, applications of iodine are no longer proper. They increase the local 
disease. There is no longer any probability of resolution of the gland, and 
poultices should be applied. 

It is important that the diseases of the osseous system should receive 



216 



SCROFULA. 



Fig. 23. 



early treatment, but, unfortuDately, it is in reference to these inflammations 
that error of diagnosis is frequently made. Thus I have known periostitis, 
with the diffused redness of the skin and heat which it produces, to be mis- 
taken for erysipelas, until the diagnosis was corrected from its persistence 
and non-extension. It is remarkable that strumous arthritis sometimes appears 
in two or more joints at once, as in the case related below. I have known it 
to occur nearly simultaneously in three joints, though only for a brief time 
in two of the joints, while it was chronic in the other. Hence, the fact that 
this inflammation is often mistaken for inflammatory 
rheumatism, and treated as such for some days till its 
nature becomes apparent, and in like manner the febrile 
movement, lassitude, abdominal pain, etc. of vertebral 
caries are in a large proportion of cases attributed to 
something else, and the true disease not suspected till 
irreparable damage has occurred, or much longer con- 
finement and treatjnent required than would have been 
necessary with an earlier diagnosis. 

The common strumous inflammations of the osseous 
system which involve the joints, as Pott's disease, hip 
disease, and white swelling, are usually quite amenable 
to treatment, early applied, which ensures complete 
rest ; but, as a rule, cases neglected or wrongly treated 
go from bad to worse. There are exceptions, for a case 
may do well or terminate with moderate deformity 
without treatment, as in the following interesting 
instance, which also shows the difiiculty which often 
attends diagnosis : 

Anna D . aged six years, came to the children's 

class in the Out-door Department at Bellevue in Feb- 
rury, 1877, with the following history : Her health was 
good till two years ago, when she complained of pain 
of a mild form in both knees. Her parents attributed 
it to her rapid growth, and she was always able to 
walk with little suff"ering. Slowly but steadily these 
joints began to swell. She has had no pain in other joints, and no member 
of the family has had rheumatism except a grandparent. She walks without 
complaint to the rooms of the Bureau. The aff'ected joints are about equally 
swollen, and it is evident on examination that they contain some serous efi"u- 
sion. Direct pressure is not painful, but pressing the bones together with a 
twisting or rotating movement gives some pain. She is pale and has a stru- 
mous aspect. A sister of fifteen years has a similar swelling of one knee 
which began at the age of seven or eight years, but which has received no 
regular treatment, has not prevented the free use of the limb, and has given 
her little inconvenience. 

The physicians who have examined this child, one of whom is an expert 
in orthopaedic surgery, agree that the disease is strumous and not rheumatic, 
and that it did not, during two years of neglect and unrestrained motion, go 
on to suppuration and destruction of the joints was probably due to her good 
general health. 

Though the result in the above case was good, since there was little 
impairment in the use of the joints and no suffering, yet delay and neglect 
in the treatment of those strumous inflammations which involve the joints 
are exceedingly dangerous, for if left to themselves they most frequently 
end in suppurative inflammation and ulceration, with all the sad conse- 
quences which these entail. Strumous inflammations of the osseous system 




STRUMOUS OPHTHALMIA. 217 

now receive more early and correct treatment than formerly, and orthopgedia, 
almost unknown till within the last twenty years, has become an important 
branch of surgery. Formerly in New York, especially in the tenement- 
houses, we often met emaciated bed-ridden children with strumous osteitis 
and arthritis, their limbs swollen and painful in motion, and offensive from 
the discharge, for the most part shunned by physicians, and with no prospect 
of relief except by amputation. Now^ this spectacle is comparatively infre- 
quent. The early symptoms of these diseases being better understood and 
sooner recognized, the plaster-of-Paris or starch dressing to ensure immo- 
bility, or ingeniously devised steel splints which produce extension and allow 
motion of the limb without friction of the inflamed surfaces, coming into 
general use, a large proportion of cases do not go beyond the first stage and 
are cured. 

Strumous Ophthalmia. 

[Written by Dr. O. D. Pomeroy, Surgeon to the Manhattan Eye and Ear Hospital.] 

Strumous ophthalmia in young children, as described by the older writers^ 
is simply a keratitis or inflammation of the cornea, and is usually of the fol- 
lowing varieties : phlyctenular or herpetic keratitis and difi"use or paren- 
chymatous keratitis. Perhaps it is a misnomer to designate these afi'ections 
strumous. This general principle governs most cases of these inflamma- 
tions — to wit, depressed vital energy, which is a prominent characteristic of 
the strumous diathesis. As is well known, the cornea is a tissue of low 
vitality, and any constitutional state accompanied by depression predisposes 
to an attack of keratitis. One of the commonest hospital experiences is to 
see a mild case of catarrhal conjunctivitis which should be self-limiting 
gradually extend to the cornea, causing an ulcerative keratitis. I believe all 
ophthalmic surgeons hold that the presence of corneal disease, not dependent 
on an obvious or specific cause, points to diminished vitality on the part of 
the patient. 

Herpetic or Phlyctenular Keratitis is the most frequent variety of 
corneal disease in children. It is a question whether it commences with a 
vesicle on the cornea or a papule ; but in either case it soon becomes an 
ulcer. Ciliary injection probably precedes it, although this can by no means 
be always observed. In some patients the characteristic symptom — to wit, 
photophobia — may exist for a long time without injection of the eyeball or 
any corneal changes whatever, but sooner or later it is probable that other 
characteristic signs of the disease will make their appearance. The photo- 
phobia is frequently accompanied b}^ blepharospasm, making it wellnigh 
impossible to separate the eyelids. When, however, this is accomplished, 
abundant tears gush forth, the child exhibiting signs of extreme distress. 
When the vesicle or papule is in a state of ulceration in the earlier stage, 
there may only be seen a minute loss of corneal tissue, without any opacity 
whatever. Soon, however, the ulcer becomes more or less opaque, perhaps 
seeming to be only a minute whitish spot on the cornea. This usually shows 
the commencement of reparative action. If the disease continue long, a 
general conjunctivitis sets in, more especially of the ocular conjunctiva. 
Frequently there will be only one or not more than two or three ulcers, but 
in exceptional cases the cornea may have the periphery studded with phlyc- 
tenulae. which, instead of promptly healing, proliferate so as to form elevated 
nodules, the so-called •* scrofulous nodular bands." If the ulcers in any case 
continue long, a number of blood-vessels shoot out from the conjunctival 
border of the cornea, quite up to the ulcer, producing what may be termed 
a vascular keratitis. The discharge from the eye is often very acrid, causing 



218 SCROFULA, 

catarrh of the lachrymal canals, and even of the nares. Herpetic or ecze- 
matous eruptions on the cheeks or the lip near the nostrils are often seen, and 
may sometimes appear to be the cause of the disease rather than the effect. 
In this condition the upper lip may swell considerably, giving the patient a 
very " strumous " appearance. 

The DURATION of phlyctenular keratitis is exceedingly variable ; two or 
three weeks may bring it to a close or it may continue many months. The 
patient's general condition probably determines its duration as much as any 
other factor. If an ulcer perforate the cornea, staphyloma and anterior 
synechia may result, rendering recovery more tedious and incomplete. The 
DIAGNOSIS of this malady is not difficult. The photophobia so characteristic 
of keratitis is present in no other disease except iritis, and this disease chil- 
dren rarely have ; the little speck, spot, or abrasion on the cornea, together 
with the intolerance of light, is wellnigh diagnostic. Photophobia is present 
in most forms of corneal disease, though not in all. The causes of phlyc- 
tenular keratitis are as follows : Any condition of the system known as 
strumous, or whatever tends to lower the vital powers of the patient, affords 
a predisposing cause. Exposure to cold or sudden change of temperature is 
the common exciting cause, leaving out of the question any cutaneous dis- 
eases. Naturally, any cause which produces a conjunctivitis may also pro- 
duce this disease secondarily. The process of dentition may have something 
to do with the eye disturbance, or any disorder of the intestinal canal ; the 
latter, however, being rather predisposing than exciting causes. This dis- 
ease also frequently occurs in patients affected with aural or nasal catarrh, 
but the condition of such children trenches closely on the state designated 
" strumous." 

The PROGNOSIS in a large number of cases is very favorable. The 
opacities of the cornea left after the healing of the ulcerations are the 
principal difficulties in the way of a good recovery. If the opacities are 
in the proper substance of the cornea, we are not certain that they will dis- 
appear by absorption, though they may. Nothing is more difficult than to 
determine this point. In the epithelial and Bowman's layers, as well as the 
posterior layer, opacities readily disappear. When the ulcer perforates the 
cornea we have an anterior synechia and the appearance known as mi/o- 
ceplialon^ which usually disfigures the eye more or less for life. 

One discouraging point about these opacities is that, although they dis- 
appear, the cornea is left with a somewhat distorted curvature, causing irreg- 
ular astigmatism, and if they chance to be near the centre of the cornea 
great disturbance to vision results. I have often, in fitting spectacles, 
noticed that the patient's vision was less than normal, and on investigation 
have found a history of an infantile keratitis which had done all the mis- 
chief. In those cases described as having " scrofulous nodular bands" the 
proliferative nodules are very likely to undergo a variety of degenerations 
which do not end in a properly restored cornea. One great difficulty in mak- 
ing an exact statement here is the tendency of the keratitis to recur, and it 
cannot be determined where the process will cease after a number of 
recurrences. 

Treatment. — As the fifth nerve presides over the ciliary vaso-motory 
system of the corneal nutritive supply, it is obvious that treatment calcu- 
lated to correct any of its morbid manifestations would be rational. Such is 
found to be the fact. Sulphate of atropia, in solution of one to two grains to 
the ounce, dropped into the eye three times daily, is probably superior to any 
other treatment. It inclines to break up the orbicular spasms, relieving the 
photophobia and ciliary neuralgia, diminishes vascularity, and contributes 
more to the relief of the patient than any other one remedy. If the pain 



STRUMOUS OPHTHALMIA. 219 



be severe, the atropine may be used six or eight times daily, or it may be 
even instilled every fifteen or twenty minutes until pain is relieved. If an 
over-effect be reached, the patient complains of dryness in the throat, possi- 
bly pain in the head, or he may have other cerebral disturbances, when the 
drops may be discontinued for a time. Muriate of pilocarpine in two-grain 
solutions may be used in a similar manner and for the same purpose ; but it 
contracts the pupil and renders the accommodation tense, the very opposite 
to the atropine effect. I have not as much confidence in this remedy. A 2 
per cent, solution of cocaine, instilled, will sometimes relieve the spasm and 
pain temporarily. Powdered calomel may be dusted into the eye every 
second day. A small quantity only should be used, since it is apt to col- 
lect in masses which act as foreign bodies (we desire to produce irritation for 
a few minutes only). A drachm of table-salt to a pint of water may be used 
to bathe the eyes freely four or five times a day, used warm or cold accord- 
ing to the patient's pleasure, although warm applications are more likely to 
be well received. Red precipitate ointment (R. Vaseline, .^j ; hyd. ox. rub. 
in very fine powder, gr. j to ij. M.) placed under the eyelids every day or 
two, is often very beneficial ; also the yellow precipitate ointment, made in 
the same manner, has a similar effect. Occasionally the ulcers show a disin- 
clination to heal, when they may be touched with Arg. nit., gr. x to xxx ; 
aquae dist., §j. M. Wind a bit of absorbent cotton on a probe, dip this into 
the solution, and touch the ulcer, but no other point. Cupri sulph., in solu- 
tion of the same strength, may be used for the same purpose. A platinum 
probe, heated to a red heat in a spirit lamp, is much used at present. A few 
drops of a 2 per cent, solution of cocaine, previously instilled, will prevent 
pain from these applications. A protective bandage exerting moderate pres- 
sure on the eye sometimes does good, but it should not feel uncomfortable. 
If there be much spasm of the orbicularis, however, it is not indicated. If 
the pain in the eye continue and the orbicularis be in a state of spasm, can- 
tholysis may be performed ; that is, divida the external canthus so as to cause 
the lid no longer to press hard upon the eyeball, and close the wound thus 
made by stitching the skin to the conjunctiva above and below the incision, 
and placing one stitch in the extreme outer canthus. The result of the 
operation is temporarily to break the power of the orbicularis, so as to 
arrest the spasm. This measure accomplishes in some cases what nothing- 
else will. 

If the eye be painful, without spasm of the lid, and there be great pho- 
tophobia, whether the eyeball be too hard or not, paracentesis may be done. 
The mode of performance is described in the treatment of ophthalmia neonati 
in another place in this book. After a while the accompanying conjunctivitis 
may need treatment in the ordinary way. Indeed, astringents may often be 
used quite early to obviate the irritating effects which occasionally result 
from the use of atropine. If an ulcer refuse to heal after the treatment 
already laid down, iridectomy may be performed, although this is not often 
resorted to. Occasionally an ulcer may be cut across by passing a narrow 
Graefe's knife through it, making a puncture on one side and a counter-punc- 
ture on the opposite side, and then cutting out quite through the ulcer, divid- 
ing it into two equal parts. All needful treatment for the constitutional 
condition of the patient should be attended to. So necessary are fresh air 
and sunlight that I would never shut the patient in a dark room. Blue or 
smoke-colored glasses may be worn to protect the eyes from a strong light, 
and in some cases the eyes may be protected by a bandage of some dark 
material, so that the patient may be taken for an airing without suffering. I 
would, however, advise to accustom the e3'es to the light as much as possible 
without causing pain. 



220 SCROFULA. 

In Parenchymatous or Diffuse Keratitis we have quite a different 
array of symptoms. The margin of the cornea near the limbus may show a 
decided zone of injection of the conjunctival and episcleral vessels. It may 
be so excessive as to consist apparently of a rosy ring surrounding the cornea. 
These vessels after a time shoot inward, and may involve a large part or even 
the whole of the cornea. In other cases, designated non-vascular diffuse 
keratitis, the injection is very slight indeed, and sometimes apparently want- 
ing altogether. In either case, however, the same consequences result : the 
cornea becomes diffusely clouded, the process generally, but not always, com- 
mencing at the limbus. This cloudiness may be quite without lines or dots 
of opacity, like ground glass. Again it may appear composed of innumer- 
able minute opaque points or lines running in various directions. At first, 
the corneal epithelium escapes, presenting a regular and uniform polish, but 
afterward it becomes opaque. Again, if the process invoLve the whole of the 
cornea, minute opaque spots may be seen in Descemet's membrane, giving it 
some of the characteristics of keratitis punctata. In the earlier stages there 
may be some pain and intolerance of light, but as a rule the disease, for a 
corneal affection, is comparatively painless. The duration of this disease is 
never short ; it may continue for many months, and it shows a strong tend- 
ency to relapse. The most frequent causes are hereditary syphilis and 
struma. Mr. Hutchinson of London always examines the teeth of these 
patients to see if there be anything characteristic of hereditary syphilis. 
As similar teeth are often noticed in strongly-marked strumous subjects, it 
becomes doubly interesting to make the observation. One point is apparent 
in most of these cases : that there are in almost every patient some signs of 
badly-developed physique — that is, faulty tissue-elaboration. As a rule, both 
eyes sooner or later become affected, pointing to a constitutional origin of the 
affection. 

In TREATMENT we are often disappointed in our efforts. At the first, if 
there be pain or photophobia, atropine may be instilled and the eyes bathed 
with warm or tepid water several times a day. Tonics or alteratives are 
always indicated. One of the most useful prescriptions is the following : 

H. Hydrars:. chlor. corros., gr. j., ad jss; 
Tine, cinchon. comp., 

Syr. aurantii, del. ^iv. Misce. 

Dose: One teaspoonful three times daily after eating. 

Iodide of potassium is frequently given, and may very properly alternate 
with the mercurial ; children will bear very large doses of the iodide, and 
indeed they are often necessary in order to obtain the curative effects of the 
drug ; I would suggest from three to twenty grains three times daily, w^ell 
diluted with water. Both these remedies may be continued for months, but 
ptyalism should always be avoided. Cod-liver oil with extract of malt may 
be administered. Whatever tends to improve the patient's general condition 
is indicated. Exercise in the fresh air is good, but the pernicious effects of 
cold must be avoided. Paracentesis of the cornea rarely does good, but occa- 
sionally iridectomy may be of benefit. The complication of iritis or irido- 
choroiditis is not common, though it does occur. When the disease becomes 
very chronic there will be hardly vascularity enough for the purposes of 
repair. This being the case, stimulating collyria may be used, similar to 
those indicated in conjunctivitis. Olive oil and spirits of turpentine, in equal 
parts, may be applied to the eye every second day. Bathing with warm 
water sufficiently to congest the eye will sometimes be serviceable. An attack 
of acute conjunctivitis has been known to do good. But, do what we may, 



ETIOLOGY. 221 

this affection sometimes runs on unchecked for a very long time. It rarely 
destroys the sight, but I recently treated a case from the beginning, and in 
spite of treatment there was only perception of light remaining. I have 
heard of only one other similar case. From some recent experiences I am 
inclined to believe that bichloride of mercury internally and atropine as a 
collyrium are of as much value as any other agents in the treatment of 
this obstinate malady. 



CHAPTER III. 

TUBERCULOSIS. 

The term -• tuberculosis " is applied to a disease which is characterized 
by the formation of small tubercles or nodules in one or more organs. 
Though more prevalent in some countries or localities than in others, it 
occurs in all or nearly all parts of the globe from which we have exact 
information, and it has been more destructive to human life than any other 
one disease. 

Etiology. — One of the most important discoveries of recent years 
relating to the etiology of diseases is that of the specific principle of tuber- 
culosis. It has long been suspected by observing phj^sicians that a specific 
cause did exist, and that this disease is to a certain extent infectious, but it 
is only recently that patient microscopic investigations have triumphed over 
the difficulties which surround this subject, and have detected the micro- 
organism which has been so fatal to the human race. The honor of its dis- 
covery belongs mainly to Dr. Koch of Berlin. In his investigations Koch 
invariably found a certain bacillus in all recent tubercles, proving beyond a 
doubt that they always accompany the development of the tubercular nodule. 
By inoculating guinea-pigs, rabbits, and cats with tubercular material he 
communicated tuberculosis, reproducing the tubercular nodule, in which he 
always found the same bacillus. But it still remained to determine the rela- 
tion of the bacillus to the tubercle, whether it was merely an accidental 
accompaniment, or whether it sustained a causal relation, producing the 
nodule by its irritating action on the cellular elements of the part where it 
happened to lodge. After man}" trials Koch succeeded in preparing a pabu- 
lum in which the bacilli grew and reproduced their kind. By adding a little 
of the first cultivation to the pabulum, he produced a second cultivation, and 
after a series of cultivations he produced a bacillus which was evidently 
freed from all other substances. With the bacillus of the last cultivation he 
was able to produce the tubercular nodule, having all the characteristics 
which are observed when it is developed in the usual way in man. Different 
micro-organisms take coloration differently, and Koch was enabled to dis- 
criminate the tubercular bacillus under all circumstances from other microbes 
by the peculiar color imparted to it. 

The tubercle bacilli have the form of " delicate rods from a quarter to 
half the diameter of a blood-corpuscle in length." The more severe the 
Tuberculosis, the greater the number of bacilli. They occur not only in the 
recent tubercle, but also in immense numbers in the periphery of the caseous 
masses of a tubercular patient. They are found not only elsewhere, but also 
in the interior of the giant-cells, as man}" as twenty even in some cells. They 
do not seem to have the power of movement, and oval spores are found in 



222 TUBERCULOSIS. 

some of tliem. They grow in a temperature of 86° to 104° F., and not in a 
temperature outside these limits. 

As might be expected, these microscopical researches of Koch have 
attracted wide attention, and have led to a repetition of his experiments by 
many pathologists, and to new experiments relating to the etiology of tuber- 
culosis. The result has been to establish more firmly the views of Koch, and 
the doctrine that tuberculosis is a specific disease, and that the bacillus is the 
specific principle, appears to be fully established. 

Among the most thorough and convincing researches bearing on the 
causal relation of micro-organisms to tuberculosis, growing out of Koch's 
discovery, were those contained in a report to the London Association for the 
Advancement of Medicine by Research {Practitioner ; London Lancet^ March 
17, 1883). Experiments were made with the cultivated bacilli obtained from 
Koch. " Twelve animals were inoculated with these organisms, chiefly into 
the anterior chamber of the eye, and all of them became tuberculous, and 
that more rapidly than after inoculation of tuberculous material. The tuber- 
cles produced in these cases were infective and caused tuberculosis in other 
animals. On examination of tuberculous material Koch's tubercle bacilli are 

always found, though in varying numbers About eighty organs of 

tuberculous animals and thirty-six cases of human tuberculosis were examined, 
and in all of these, without exception, tubercle bacilli were found," 

The discovery of Koch has already proved of great importance as an aid 
in diagnosis, for the sputum of tubercular patients contains the bacillus. 
Tubercular sputum affords a soil in which the bacillus thrives and multiplies, 
as it does in the tissues of a tubercular patient, and by careful microscopic 
examination we are able to discover it in this sputum, while it is absent 
from non-tubercular sputum. According to Frisch ( Wiener med. Wocli..^ 
No. 46, 1883), the bacilli were found without an exception in the sputum 
of 140 patients with confirmed tuberculosis, while the sputum of 150 
non-tubercular patients was in every instance free from them. Heitler 
(^Wiener med. Woch., No. 43, 1883) examined the sputum of 140 tuber- 
cular patients, 1 of whom had miliary tubercles, and 1 other caseous 
pneumonia. All the other cases were chronic and were grouped by the author 
as follows : 1st, 6 cases of old infiltration of the apices of the lungs, cured 
with the persistence of dulness on percussion, without rales ; no bacilli 
observed. 2d, 12 cases of tuberculosis with slight dulness and dry rales. 
In 2 of these, notwithstanding marked physical signs, fever was absent and 
the tubercular process was arrested apparently ; no bacilli. In the sputum 
of the remaining 10 cases bacilli were present in all the examinations except 
2. The third group contained cases of advanced and progressive tuberculosis, 
and the fourth group cases of advanced chronic phthisis, but with remissions. 
In the sputum of these two groups bacilli were always observed. That Heit- 
ler in 6 instances witnessed the disappearance of bacilli when the tubercular 
process was arrested is an interesting fact, as showing the relation of the 
bacilli to tuberculosis. He examined the sputum of 29 non-tubercular 
patients, patients with pneumonia, bronchitis, bronchial dilatation, and putrid 
bronchitis with gangrene, and in no instance found the bacilli of tuberculosis. 

As usually happens when a great discovery is announced, there are dis- 
sentients; there are those apparently competent to express an opinion, as 
Spina and Formad, who do not accept, or only partly accept, the views of 
Koch. But the testimony of many observers, constantly accumulating, tends 
to establish more securely the doctrine of the parasitic origin of tuberculosis, 
and it is now apparently as securely established as most doctrines in pathology. 

Koch's discovery necessitated revision of the teachings long accepted 
relating to tuberculosis. The tubercle nodule is, as we will see, an aggre- 



ETIOLOGY. 223 

gation of cells produced from the cellular elements of the part where the 
nodule appears through a proliferating process caused by an irritant, and in 
the light of our present knowledge we consider the bacillus to be the irritant. 
A local corpusculation and a cellular nodule may be produced in the lungs or 
elsewhere by the lodgment of a non-specific irritant, whether organic or inor- 
ganic, as putrid cheese, particles of dust, or metallic particles, and thus far no 
cells have been discovered in nodules thus produced which are characteristic 
of tuberculosis. The giant-cells which at one time were thought to be pecu- 
liar to the tubercular nodule have been found in growths of another nature, 
as in gummata. The characteristic and peculiar element in the tubercular 
nodule is the bacillus. 

It has long been the belief from clinical observations in Southern Europe, 
and of certain observing physicians in the temperate regions of Europe and 
America, that phthisis is contagious, and the acceptance of the parasitic 
theory will probably soon render this belief an established principle in pathol- 
ogy. Already many instances have been published in the journals which 
appear to show the infectiousness of tuberculosis, as the following : In an 
inland town in Europe a midwife with, advanced phthisis had been in the 
habit of blowing into the mouths of new-born infants, and so many of them 
perished of tubercular disease as to excite attention and cause alarm, while 
those attended by a healthy midwife remained well. Dr. E. I. Kempf relates 
the following striking example in the Louisville Medical News for March 22, 
1884: In the fall of 1880 a girl of eighteen years, whose brother had died of 
consumption, was found to have tubercles at the apices of both lungs. She 
belonged to a sisterhood, and slept in the general dormitory with the other 
sisters. In four months nine of her companions began to cough and were 
found to have tubercles. No one of the sisterhood had previously had dis- 
ease of this kind. Dr. A. Ollivier, physician to I'Hopital des Enfants-malades, 
Paris, states that a family having uniform robust health occupied two small 
rooms opening into a narrow court. The parents, a young son, and the baby 
slept in one of the rooms. An older son. who had been living elsewhere, 
contracted phthisis, returned home, and slept in the same apartment. He 
died January 16, 1883. His mother, who was constantly at his bedside, 
began to cough, emaciated, and died of the same disease in the following 
May. Seven days after the death of the mother the infant had tubercular 
meningitis, of which it perished ; and the older child, who occupied the same 
apartment, sickened and died like the^ mother. The father only survived of 
those who occupied the small room (Etudes d' Hygiene puhJique^ 1886). The 
fact that wives devoted in their attendance on consumptive husbands fre- 
quently perished of the same disease physicians in various countries have 
long remarked, but it has usually been attributed to the depressed state of 
system incident to long watching and grief, and not to any contagious prop- 
erty. But now that a clearer insight has been obtained into the nature of 
tuberculosis, and both microscopical researches and clinical facts indicate its 
communicability, more caution will be exercised in the intercourse with 
patients. 

The recent experiments of Cornet (Wiener med. WocJien., June 2, 1888) 
appear to show that the walls and furniture of a room occupied by a phthis- 
ical patient may be infected by the lodgment of the tubercle bacillus upon 
them, so that any one occupying this apartment subsequently is in danger of 
contracting the disease. He rubbed the walls and bedsteads in the ward occu- 
pied by phthisical patients with disinfected sponges, avoiding such surfaces as 
might be infected by the hands and sputum of patients ; 94 animals were 
inoculated with these sponges, and 52 of them died, apparently of causes 
different from tuberculosis ; the remaining 44 were killed after forty days, and 



224 TUBERCULOSIS. 

20 of them bad tubercles. 168 animals were inoculated with the dust from 
the walls of rooms occupied by phthisical patients in family practice. Of 
these animals 90 died soon afterward. Of the remaining 78, 34 contracted 
tuberculosis. In control-experiments, the dust being used from surgical 
wards, operating-rooms, and from crowded thoroughfares, the result was neg- 
ative as regards the production of tuberculosis. " It has been abundantly 
demonstrated by numerous experiments that the milk from tuberculous cows is 
capable, when ingested, of causing tuberculosis. How serious is this danger 
may be seen from the statistics of Bollinger, who found the milk from cows 
affected with extensive tuberculosis infectious in 80 per cent, of the cases, 
and that from cows with moderate tuberculosis infectious in 33 per cent, of 

the cases Bollinger estimates that at least 5 per cent, of the cows in 

dairies are tuberculous. From statistics furnished me by Mr. A. W. Clement, 
V. S., the number of tuberculous cows in Baltimore which are slaughtered is 
not less than 3 to 4 per cent." ^ 

The causal relation of scrofula to tuberculosis we have considered elsewhere, 
but we may here repeat that scrofulous ailments, especially the caseous prod- 
ucts, afford the soil which is favorable to the growth and multiplication of 
the bacilli. Hence these microbes are not infrequently found in scrofulous 
products, showing that the tubercular has supervened on the scrofulous dis- 
ease. Kanzler treats of the relation of scrofula to tuberculosis in the Berlin. 
klin. Woch., January 14, 1884. He believes that the two diseases are distinct, 
but that, as expressed by the French reviewer, la scrofule offre vn terrain de 
predilection pour It developpemient de la tuherculose. He has discovered bacilli 
only in a minority of the local manifestations of scrofula, never in glands 
which had not undergone suppuration or caseation, never in eczema, impetigo, 
suppurative otitis media, and never in the nasal, conjunctival, pharyngeal, 
and vaginal catarrhs of the scrofulous. It is not till degenerative changes 
have occurred in the inflammatory products of scrofula that the bacilli of 
tuberculosis appear, indicating the supervention of the latter disease. 

Anatomical Characters of the Tubercle. — As Yirchow pointed out, 
the tubercular nodule when recent is semi-translucent and small, attaining 
about the size of a millet-seed and consisting mainly of cells. The cells of 
which it is chiefly composed resemble the white corpuscles of the blood in 
appearance and size, but some are smaller and others larger than those cor- 
puscles. They have been designated the lymphoid cells. Each cell when 
fully developed has a bright homogeneous nucleus, small and spherical or 
large and oval, and nucleoli. A large cell sometimes contains two or more 
nuclei. The lymphoid cells appear to be developed from the cellular element 
of the connective tissue. This is Virchow's belief. In addition to these cells, 
which constitute the greater part of the tubercle, large uninuclear cells are 
also observed, designated epithelioid cells. They resemble large and swollen 
endothelial or epithelial cells, aud they are believed by pathologists to be pro- 
duced from these cells, which lie within the area of the nodule. A third cell 
also occurs, known as the giant-cell from its size. It has many nuclei, and 
occupies chiefly the central part of the nodule. All these cells, as has been 
recently shown, occur in other pathological products besides the tubercular 
nodule, and no one of them is therefore characteristic of it. But the element 
which is of greatest importance, since it sustains a causal relation to the 
disease, was, as we have seen, the last discovered. The bacillus is always 
found in the recent tubercle lying without the cells, as we have stated, but 
also in the interior of the giant-cells, for which it appears to have an affinity. A 
fibrous network with more or fewer blood-vessels surrounds the cells and holds 
them together. The blood-vessels belong to the normal tissues, and are not 
1 Prof. W. H. Welch's Address before the Amer. Med. Asso., 1889. 



ETIOLOGY. 225 

a new growth, the tubercle having developed around them. The tubercles 
are single or in clusters, forming masses of considerable size. 

When the tubercle has attained a certain age, caseation always occurs 
in its centre and extends outward, causing an opaque and yellowish-white 
dead mass, in which fragramentary cells can be observed under the micro- 
scope. Caseation is now known to be a form of decay which is common to 
pathological products of different kinds, and is not peculiar to tuberculosis, 
as was supposed before the time of Virchow. It occurs in consequence of 
abundant exudation or cell-formation and the compression and obliteration 
of vessels. It is therefore more common in scrofula than in any other dis- 
ease, since scrofulous inflammations afford the conditions in which it is espe- 
cially liable to occur. The yellow tubercle is therefore only an advanced stage 
of the semi-transparent or miliary tubercle. In the cheesy metamorphosis 
granules of fat are deposited within and around the cells, and the cells shrivel 
and disintegrate. The shrunken granular and fragmentary cells were believed 
to be the true tubercular cells until Virchow pointed out their character. 
When the tubercle or tubercular mass becomes yellow or caseous, and circu- 
lation ceases in it, it is surrounded by a vascular zone in which circulation 
still continues. It is very seldom, perhaps never, absorbed, although parti- 
cles of it may enter the lymphatics or blood-vessels and be carried elsewhere 
with the bacilli. It is an irritant, producing inflammation in the surrounding 
tissues, with thickening, induration, and abundant production of pus-cells, 
which mingle with the elements of the tubercle. Its history henceforth is 
that of an abscess, and ulceration and discharge of the liquefied substance 
upon one of the free surfaces is the common result. In rare instances the 
tubercle, instead of cheesy degeneration, undergoes fibroid degeneration or 
cretefaction. 

Various pathological conditions furnish the soil in which the bacillus 
obtains lodgment and grows, and in this way becomes a cause of tubercu- 
losis. Cheesy pneumonia and exhausting suppurative surfaces often afford 
a nidus favorable for the development of the tubercle bacillus. During epi- 
demics of measles many cases occur of cheesy pneumonia ending in tuber- 
culosis. Cheesy and disintegrating lymphatic glands, as the bronchial, often 
become tubercular. 

Anatomical Characters in Infancy and Childhood.— The anatom- 
ical characters of tuberculosis in the first years of life vary in certain par- 
ticulars from the form which they present in the adult, but after the age of 
three years the differences are fewer and less pronounced than previously. 

Tubercular laryngitis, so common in the adult, is absent in a large pro- 
portion of cases under the age of three years, and when present it has little 
intensity. Ulceration of the larynx very seldom occurs. This has been 
attributed to the fact that there is so little expectoration in young children, 
the sputum being an irritant. Niemeyer, however, does not consider the 
sputum of tuberculosis sufficiently irritating to cause laryngitis and laryn- 
geal ulceration ; but the arguments in favor of this mode of causation, in 
my opinion, more than counterbalance those which have been presented 
against it. 

I have never met a case of tubercular ulceration of the larynx or trachea 
in the post-mortem examination of young children, nor do I recollect ever 
treating a case in which there was that degree of dysphonia which indicated 
ulceration. Rilliet and Barthez, in more than 300 necropsies of tubercular 
cases, found no ulcers in the larynx or trachea under the age of three years, 
but met 8 cases between the ages of three and ten years, and 8 between ten 
and fourteen years. The ulcers, whether seated in the larynx or in the 
trachea — and they are in most cases in the former, since the inequalities 

15 



226 TUBERCULOSIS. 

upon the surface of the larynx favor the retention of the sputum — are com- 
monly small, superficial, round or elongated, and with little thickening or 
infiltration of their borders. Occurring in the folds of the mucous mem- 
brane — as, for example, around the vocal cords — their form is usually elon- 
gated. 

Bronchitis is not infrequent. This inflammation is due to, and depend- 
ent on, the pulmonary tubercles, and is therefore most intense in the part of 
the lung where the tubercles are most abundant and farthest advanced. 
Consequently, it is more intense on one side than on the other, and it may 
be unilateral. It differs in this respect from idiopathic bronchitis, which is 
commonly nearly uniform on the two sides. It differs also in the fact that 
it is sometimes accompanied by ulcerations. The ulcers are round or elon- 
gated in the direction of the axes of the tubes, and, like those of the larynx 
or trachea, are superficial. Circumscribed inflammation may attack a bron- 
chial tube, as, indeed, the trachea, and give rise to ulceration and perforation 
from the pressure of a diseased lymphatic gland external to the tube. This 
subject will be treated of hereafter. 

Lungs. — It is well known that in the adult tubercles are always present 
in the lungs if they occur in any part of the system. I have met 2 cases 
in which the lungs were free from tubercles in 36 post-mortem examinations 
of children who died of tuberculosis. One of the two was an infant, but its 
exact age is not stated in the records. It had cheesy degeneration of the 
thymus and bronchial glands, enlargement of the mesenteric glands, but 
without cheesy degeneration, and disseminated tubercles in liver and spleen. 
The other, fifteen months old at death, had tubercular meningitis, with nume- 
rous granulations upon the convexity of the brain, and the other usual 
lesions of meningeal inflammation, with bronchial and mesenteric glands 
slightly enlarged and cheesy, and one of the former softened. In 1 case, 
then, in 18 the lungs had escaped the disease. Rilliet and Barthez in their 
statistics of the state of the lungs in infancy and childhood found these organs 
non-tubercular in 47 cases in 312, and Hillier in 25 cases in 160. Therefore, 
the lungs were exempt from tubercles in about 1 case in 7. But it is to be 
recollected that the observations of these physicians were made at a time 
when all cheesy degenerations were thought to be tubercular, so that their 
published statistics may not have been strictly accurate. 

Pulmonary tubercles in children under the age of three years are, as a 
rule, discrete and disseminated through the lungs. In cases at this age 
which have advanced to a fatal termination we find yellow tubercles from 
the size of a pin's head to that of a shot in the different lobes ; many still semi- 
transparent if the disease have been of short duration, but if protracted 
most of them yellow, and here and there one softened and surrounded by 
condensed fibrous tissue. Around the semi-transparent or gray tubercles, 
many of which were growing, and therefore were in the state of active cell- 
proliferation at the time of death, vascular zones can often be detected by 
the naked eye. 

Under the age of three years tuberculosis exhibits but little tendency, 
perhaps none, to affect the upper lobes sooner or in greater degree than 
the lower. 

The following are the statistics relating to the site of the tubercles in the 
lungs in the cases which I have examined ; all, it is to be remembered, were 
under the age of three years : 

Cases. 
Tubercles disseminated tliroughout the longs .......... 26 

Tubercles disseminated throughout the two upper lobes 3 

Tubercles disseminated through right middle lobe and left lower 
lobe only 1 



ETIOLOGY. 227 

Cases. 

Tubercles disseminated through left upper lobe only 2 

Tubercles disseminated (few and semi-transparent) in left lung 

only 1 

Tubercles disseminated in three points in right and two in left 

lung 1 

No tubercles in lungs 2 

36 

Between the ages of three and fifteen years statistics show that the 
upper lobes are more liable to tubercles than the lower ; but the difference in 
liability is not great. In many cases occurring in this period the different 
lobes are affected nearly simultaneously, and not very infrequently the upper 
lobe is the last which is involved. In October, 1866, I made the post-mor- 
tem examination of a boy who died in the Children's Service of Charity 
Hospital at the age of fifteen years, and small scattered tubercles were 
found in the lower lobe of the left lung, while all other portions of these 
organs were healthy. Rilliet and Barthez, who include in the same statistics 
all cases from birth to the age of fifteen years, found gray semi-transparent 
tubercles — 

Cases. 

In the right superior lobe in 63 

In the right middle lobe in . 43 

In the right lower lobe in 55 

In the left superior lobe in 65 

In the left inferior lobe in 54 

The same observers found yellow tubercles in the 

Right superior lobe in 40 

Eight middle lobe in 28 

Right inferior lobe in 39 

Left sujjerior lobe in 35 

Left inferior lobe in ~ 31 

Tubercle, especially when softening commences, is itself an irritant, 
exciting inflammation around it. Inflammation occurring from this cause 
is obviously likely to be protracted, continuing for weeks or months unless 
the tubercular matter be eliminated by ulceration. The highly vascular and 
delicate lungs of the young child are very liable to inflammation when they 
are the seat of tubercles, and as the tubercles are disseminated, the pneumo- 
nia is commonly more extensive than when it occurs from ordinary cases. 
-In fifteen, or nearly one-half, of my cases there was pneumonia affecting 
portions of one or more lobes or an entire lobe. From the extent and posi- 
tion of the solidified portions it was obvious that in mOvSt instances the 
inflammation originated from the irritating effect of the tubercular matter, while 
in others it was due to hypostatic congestion, occurring in consequence of 
the long-continued recumbent position and feebleness of circulation. In 
these 15 cases the, seat and extent of the pneumonia were as follows : 

Cases. 

Nearly entire right lung 2 

Nearly entire middle and lower lobe of right lung 1 

Entire left upper lobe 2 

A considerable part of both lungs 1 

Posterior parts of both lower lobes 4 

Posterior part of left lung 1 

Left lower lobe, and right middle and lower lobes 1 

Left upper lobe (contained a large cavity) and posterior part of left 

lower lobe 1 

Nodules of inflamed lung around tubercles 2 



228 TUBERCULOSIS. 

The inflammation in about one-third of the cases was due to hypostasis, since 
it occurred in depending portions, extended but little into the lungs, and sus- 
tained no relation to the amount of tubercle. Tt was in the stage of red — or, 
more rarely, of gray — hepatization. 

In 7 of the cases there were pulmonary cavities as large in proprotion as 
we ordinarily find in tuberculosis of the adult. The seat of 1 was in the 
right lower lobe ; of 2, the left upper lobe ; of 1, the right upper lobe ; of 
another, the right lung, its exact seat not stated ; and in the remaining case 
the cavity^, which was the largest of all, occupied the interior of all three 
lobes on the right side. Some idea of the size of these cavities may be 
learned by the following extracts from the records : 1st Case. " A small 
superficial cavity communicating on one side with a bronchial tube, and on 
the other side with a small circumscribed collection of pus in the pleural 
cavity." 2d Case. " Cavity of the size of a hickory-nut." 3d Case. '' Cavity 
of the size of a large hickory-nut." 4th Case. " Cavity three-fourths of an 
inch in diameter." 5th Case. '• A large abscess." 6th Case. " The cavity 
occupied nearly the whole of the interior of the left upper lobe." 7th Case. 
" About half the right lung excavated into a cavity which extended through 
the three lobes." 

Circumscribed pleuritis, produced by tubercles underneath the pleura, was 
observed in 7 cases. It was ordinarily attended by little exudation except 
the fibrin, but in 1 case a sufiicient amount of serum had been exuded to 
compress considerably the lung. Pus was not observed in any notable 
quantity. 

Emphysema was present in several cases, chiefly in the upper lobes, some- 
times vesicular, with fulness or bulging of the lung, an ansemic appearance 
of it, and doughy, inelastic feel. In other cases emphysema was interstitial, 
producing little bladders of air under the pleura, especially toward the root 
of the lung, or separating the lobules by wedge-shaped or irregular inter- 
spaces filled with air. In one case air had escaped from an emphysematous 
bladder into the right pleural cavity, causing pneumothorax and collapse of 
the lung. 

Next to the lungs, the bronchial glands are more frequently diseased than 
any other organs in the tuberculosis of infancy and childhood. They undergo 
the successive structural changes which characterize glandular inflammations 
— to wit, hyperplasia — and more or fewer of them cheesy degeneration and 
softening. In the state of hyperplasia their firmness is diminished and they 
have a pale flesh-color. Cheesy degeneration commences in one or more 
points in the gland, sometimes in the peripheral, sometimes in the central 
portion, and it extends till the whole gland presents the well-known cheesy 
appearance. When the gland softens the thick liquid has a puriform appear- 
ance, consisting of amorphous matter, fatty particles, and the shrivelled and 
disintegrated cells of the gland. Soon pus-cells occur, and their number 
increases. The cheesy gland may or may not be tubercular. If it be tuber- 
cular, the tubercle bacillus will be found in it. 

Killiet and Barthez state that the bronchial glands were tubercular 
(caseous) in 249 cases in children, while the lungs were tubercular in 265. 
All cheesy glands, it is to be recollected, they considered tubercular. In 4 
of the 36 cases which I have examined no record was preserved of the state 
of the bronchial glands ; in 1 case there was no perceptible hyperplasia and 
no cheesy degeneration ; in 2 there was hyperplasia, but no cheesy degener- 
ation, while in the remaining 29 cases cheesy degeneration had occurred in 
some of the glands or in parts of them, with occasional softening. The 
enlarged and caseous bronchial glands afford an explanation in part of the 
fact that the symptoms in the tuberculosis of young children difl"er from those 



ETIOLOGY. 229 

in the adult, since Louis found the bronchial glands involved in only 28 per 
cent, of the adult cases of tuberculosis which he examined, and Lombard in 
only 9 per cent. A gland pressing upon the recurrent laryngeal or pneu- 
mogastric nerve or the trachea may give rise to dyspnoea and a cough ; or 
on the descending vena cava or one of the venae innominatse to congestion of 
the brain and meninges, intracranial serous effusion, and even thrombosis in 
the cranial sinuses. That a softened bronchial gland is not infrequently 
eliminated from the system by ulceration into a bronchial tube or into the 
trachea is well known. In one case which I observed the ulceration had 
destroyed portions of three of the cartilaginous rings of a bronchus, and the 
aperture was plugged by a cheesy fragment of a softened gland which pro- 
truded. Occasionally, it is stated by authors, the ulceration is into one of the 
large vessels of the mediastinum, or even into the oesophagus. 

The following is an example of bronchial phthisis as it commonly occurs. 
This case, which is not included in the foregoing statistics, was seen almost 
daily by me during its entire progress : On September 3, 1874, I examined 
an infant in the New York Infant Asylum who had wheezing respiration 
during the last eight days. The wheezing occurred both in inspiration and 
expiration, and also, though less pronounced, during sleep; pulse 96, respi- 
ration 40, temperature normal. Its mother, who had charge of it, and had 
till recently wet-nursed it, had unequivocal symptoms of tuberculosis for 
several months. The child was pallid and its flesh was soft and flabby. 
The fauces were perhaps a little redder than usual, but were otherwise nor- 
mal, and a careful exploration of the chest revealed no cause of the embar- 
rassed respiration. Auscultation and percussion gave a negative result. In 
the latter part of September a troublesome diarrhoea occurred, which con- 
tinued more or less till near death. The temperature on September 28th, 
October 8th, 10th, and 11th, was 100i°, 100°, 99*°, and 100°. The pulse on 
October 10th and 11th was 120 and 126. On October 8th the percussion- 
sound over the upper part of the right lung seemed somewhat duller than 
on the other side, though the respiration was not observed to be notably 
changed in the area of the dulness. There was but little cough during the 
entire sickness. Death occurred on October 20th. At the autopsy the 
bronchial glands were found enlarged and cheesy, and underneath the right 
bronchus, near the bifurcation, was a softened, almost diffluent gland, as 
large as a small hickory-nut and compress- 
ing the bronchus. This, no doubt, had Fig. 24. 
produced the wheezing respiration, which 
had been the chief local symptom. The 
lungs, spleen, and in less degree the liver, 
contained numerous small miliary tuber- 
cles. Certain of the mesenteric glands 
were also cheesy, but to a less extent than 
the bronchial. The disease of the bron- A 
chial glands was^ evidently primary, the l^ 
tubercles of the lungs and abdominal or- M^^ 
gans being apparently quite recent. The r^, 
accompanying woodcut, from a photograph 
by Mr. Mason, the photographer at Belle- ' 
vue Hospital, represents a posterior view / 
of the lungs and air-passages. (i^iP^^^' 

In no case have I found tubercles in 
the heart or pericardium, though they 

have been observed in rare instances in the latter. The mesenteric glands 
were enlarged by hyperplasia and more or less cheesy in 30 cases, were 





230 TUBERCULOSIS. 

apparently normal in 2 cases, while in the remaining 4 cases their condition 
was not stated. In most of the patients the mesenteric glands were smaller 
and less cheesy than the bronchial, but in a few instances they were larger 
than the bronchial and more cheesy. 

It is a noteworthy fact, as bearing on the causal relation of these glands 
to tubercles, that not infrequently the amount of hyperplasia and cheesy, 
degeneration occurring in the former was very considerable, while the tuber- 
cles in the lungs or elsewhere were small, even minute, semi-transparent, and 
apparently of recent formation. It was evident in such cases that the 2:land- 
ular hyperplasia and degeneration, bronchial or mesenteric, or both, preceded 
the tubercular disease, and furnished the conditions favorable for the lodg- 
ment and propagation of the tubercle bacillus. Since the cases which fur- 
nished the above statistics occurred my clinical experience with tuberculosis 
has greatly increased, but nothing new or different has been observed at 
autopsies. 

Abdominal Viscera. — In children tubercles in the solid organs of the 
abdomen rarely give rise to appreciable symptoms, since they are small and 
disseminated, not impairing materially the function of the part in which they 
are located. On the other hand, peritoneal and intestinal tubercles and the 
enlarged and cheesy mesenteric glands give rise to symptoms which require 
description. The most frequent seat of peritoneal tubercles is upon the 
attached surface of the peritoneum, where they are formed in the connective 
tissue. They are distinctly seen through the peritoneum, and cause some 
prominence of it. Exceptionally their seat is upon its free surface. Every 
portion of the peritoneum, whether visc'eral, parietal, or omental, is liable to 
tubercles, but general tuberculization of so extensive a surface seldom 
occurs in any one case. The tubercles are spherical or lenticular, and most 
of them small. Sometimes they are very numerous, but so minute as to be 
scarcely visible. They are gray or yellow according to their age. Peri- 
toneal tubercles often produce circumscribed peritonitis, causing adhesion of 
opposite surfaces. The tubercles in themselves cannot be detected by exter- 
nal palpation ; but masses composed of tubercles and inflammatory products 
are sometimes so large that they can be felt through the abdominal walls. 

The symptoms of peritoneal tuberculosis are attributable, for the most 
part, to the peritonitis. Among them may be enumerated abdominal tender- 
ness or pain, meteorism, ascites — usually slight — and derangement of the 
bowels, commonly diarrhoea. Since tubercles in this situation occur, in most 
cases, subsequently to tubercles elsewhere, the symptoms which have been 
described are associated with and are subordinate to others. 

Stomach and Intestines. — The most common seat of gastro-intestinal 
tubercles is the small intestine, and more frequently its lower portion, near 
the ileo-csecal valve, than its upper or central. They are rare in the duo- 
denum or contiguous part of the jejunum. They are developed ordinarily 
in the connective tissue, either that lying under the mucous or the serous 
surface. 

Gastro-intestinal tubercles are often accompanied by ulceration of the 
adjacent mucous membrane. But in a certain proportion of cases, probably, 
the tubercles do not cause the ulcers, for ulceration of this membrane is not 
infrequent in the tuberculosis of children, when there are no tubercles in the 
walls of the stomach or intestines. The following statistics of Killiet and 
Barthez relating to this point will aid to an understanding of the symptoms : 

rr, 1 1 • 11 r ^ I ^- J with ulcers, 6 cases, 

iiibercles in walls ot stomach, / cases, <^ •^.1,^.1 1 

' ' i without ulcers, 1 case. 

Ulcers of gastric mucous membrane, without gastric tubercles, 14 cases. 



Spleen. 


Kidneys. 


22 


1 


6 


21 


8 


14 









SYMPTOMS. 231 

rn 1 1 • n • ^ X- oo f ^vith ulcers, 70 cases. 

Tubercles in small intestine, §2 cases, | ^^..^^^^^^ ^^^'^^.^^ ^2 cases. 
Ulcers without tubercles in small intestine, 51 cases. 

rr, , 1 . 1 . , ^- -, r ( with ulcers, 10 cases. 

Tubercles in large intestine, 15 cases, | ^^.^j^^^^^^ ^^^^'^^^^ ^^^^^_ 

Ulcers in large intestine, without tubercles, 47 cases. 

The ulcers have vascular, thickened, and infiltrated borders. Their diam- 
eters vary from a line to half an inch or more, and their general form is 
circular, or, if two or more unite, irregular. Tubercular ulcers of the 
stomach are mostly in the great curvature, those in the small intestines in 
the ileum and lower part of the jejunum, and those of the large intestine in 
the caecum. 

The following table exhibits the state of the principal abdominal viscera 
in the 36 cases embraced in my statistics : 

Liver. 

Tubercular 12 

Non-tubercular 16 

Not stated 8 

Fatty 5 

In no instance did I observe tubercular softening in the abdominal organs, 
and a large proportion of the tubercles in the liver, spleen, and kidneys were 
still in the first stage. In the 5 cases in which the liver was recorded fatty 
this state of the organ w^as obvious to the sight, as it is in tuberculosis of 
the adult. A moderate excess of fat in the hepatic cells may have been 
present in some of the other cases, but it was not sufficient to be appreciable 
without the microscope. It is to be remarked that in the 5 cases in which 
the liver was recorded fatty this organ contained no tubercles. The spleen 
is seen to have been the most frequent seat of tubercles of all the viscera, 
except the lungs. In 14 cases the intestines were examined ; and in 5 
tubercles discovered, developed in their connective tissue. The intestinal 
tubercles were small, and ulceration had occurred of the mucous membrane 
which covered them. 

The brain was examined in 15 cases. In 12 the amount of cerebro- 
spinal fluid varied from ^ss to ^v by estimation. In 2 others the records 
state that there was a considerable amount of this fluid, the exact quantity 
not being given, while in the remaining case congestion of the brain and 
meninges was noticed, but nothing was recorded in regard to the amount of 
cerebro-spinal fluid. The increase of the cerebro-spinal fluid in tuberculosis 
is attributable to wasting of the brain, a hi/drocephalus ex vacuo, and in some 
cases to passive congestion and serous transudation, due to feeble circulation, 
or obstructed flow from the pressure of bronchial glands on the vessels within 
the thorax, as already stated. 

Tubercles were present in the pia mater in 3 cases : in 2 with fibrinous 
exudation ; in the other without fibrin or other evidence of inflammation. 
Tubercular meningitis is described in another part of this book. 

Symptoms. — The symptoms in tuberculosis of children arise in part from 
the diathesis and in part from the tubercles. Before the period of tubercles 
there are signs of failing health, such as loss of appetite, flabbiness of the 
soft parts, or emaciation, lassitude, and loss of strength. These symptoms 
continue after the formation of tubercles, and increase. 

The features are ordinarily pallid, but during the paroxysms of fever, to 
which tubercular patients are subject, they may be flushed. Lividity of the 
features, due to imperfect decarbonization of the blood, occurs if there be 
enlarged bronchial glands which compress the vessels within the thorax, or 



232 TUBERCULOSIS. 

if there be extensive pulmonary tuberculization or pulmonary tuberculiza- 
tion, whether extensive or not, which is complicated by capillar}^ bronchitis 
or pneumonia. 

The skin is nearly natural, or it loses its flexibility and softness and 
becomes dry and rough. In some patients there is, at times, general or par- 
tial furfuraceous desquamation of the skin, due to exaggerated development 
of the epidermis. Children, like adults, notwithstanding the general dry- 
ness of the surface, are liable to perspirations at night and in sleep. This 
symptom is less frequent at the commencement than at an advanced period, 
in acute than in chronic cases, and in those under three or four months than 
in older children. It is more abundant about the head and limbs than else- 
where, and is sometimes confined to these parts. 

Anasarca is not infrequent. It sometimes arises from obstructed circula- 
tion in consequence of compression of the thoracic vessels by enlarged 
lymphatic glands ; in other cases it is due to diminished plasticity of the 
blood, a result of the tubercular cachexia. The latter is the more common 
cause. It is not an important symptom, on account of the small amount of 
serous transudation and the character of the parts in which it occurs. 

Emaciation, already alluded to, is early, constant, and progressive. Under 
the age of six or eight months it is less marked than in older children, many 
preserving considerable rotundity of features and form even in advanced 
tuberculosis. The failure of the strength corresponds in amount and prog- 
ress with the emaciation. Slight at first, and exhibited only by a degree of 
lassitude, it gradually increases, till for weeks before death the little patient 
is fatigued by the ordinary muscular movements, and is inclined to be quiet. 

The nervous system is not ordinarily affected except in cases of intra- 
cranial tubercles. In acute tuberculosis or tuberculosis complicated by 
severe inflammation there may be agitation and delirium, especially at 
night. 

In most patients the mucous membrane of the buccal cavity presents its 
normal appearance, with the exception of a moist fur upon the tongue and a 
paler hue than normal of its surface generally. In acute tuberculosis and in 
cases complicated by inflammation the tongue is sometimes dry and brown. 
The appetite may be normal till the close of life or it is poor or changeable. 
Occasionally it is increased, although the disease is progressing. The bowels 
are regular or relaxed. Diarrhoea may be a prominent symptom, even when 
there are no intestinal tubercles or ulceration. Meteorism and fulness of the 
abdomen are common. 

Fever, constant, but usually with evening exacerbation, is rarely absent. 
It continues for weeks or months. During the exacerbation the pulse rises 
to 120, 140, or even to 180 beats per minute, and there is a corresponding 
exaltation of the temperature, which in the latter part of the day, without 
inflammatory complication, ranges from 100° to 102° or 103°. The febrile 
movement is a symptom of diagnostic value as regards the nature of the dis- 
ease, though it does not indicate the seat of the tubercles. 

In addition to the symptoms now described, there are special symptoms 
due to tuberculization of the diff"erent organs. In young children, on account 
of the fact already referred to — to wit, the tendency to a generalization of 
tubercles — there is often a blending of the symptoms which arise from dif-- 
ferent organs, but with care it is not difficult in most instances to isolate and 
refer them to their proper source. The following are the symptoms which 
arise from tuberculization of the more important organs : 

Encephalon. — The symptoms produced by tubercles of the encephalon 
vary according to their seat and size and the structural changes in surround- 
ing parts to which they give rise. Meningeal tubercles, which are located 



SYMPTOMS. 233 

for the most part in tlie meshes of the pia mater, and ordinarily along the 
course of the small arteries, are, as a rule, small, not more than a line in 
diameter, and they may remain latent for a considerable time. In the 
majority of cases, however, they sooner or later cause meningitis, the 
symptoms of which are well known and need not be described. But 
tubercles in this situation do sometimes give rise to symptoms when 
there is no meningeal inflammation. They occasion congestion of the sur- 
rounding vessels and serous transudation, and, if developed on the under 
surface of the pia mater, they may produce symptoms by encroaching upon 
and irritating the brain ; for they are sometimes so much imbedded in the 
convolutions that careful examination is required in order to determine that 
they are meningeal and not cerebral. Among these symptoms may be 
mentioned headache, frontal or occipital, sometimes intermittent, nausea, 
melancholy, and in certain cases the symptoms produced by serous trans- 
udation. 

The symptoms of cerebral are in part similar to those of meningeal 
tuberculosis, but in most cases others of a neuropathic character are 
present, which serve for differential diagnosis. The differences as regards 
the symptoms of different patients having cerebral tubercles are attribut- 
able in part to their size and rapidity of growth, but more to the differ- 
ence in their seat ; for any part of the brain may be the seat of tubercles, 
though certain portions, as the cerebellum, are more frequently affected than 
others. 

The child with cerebral tubercles is quiet, but irritable and easily excited. 
Delirium is not common, but many before the close of life exhibit a degree 
of mental dulness. The headache, common in cases of cerebral as well as 
meningeal tubercles, may be nearly general, or it is frontal, parietal, or occip- 
ital according to the seat of the tubercles. It is often lancinating, often 
intermittent. 

Clonic convulsions occur toward the close of life. Exceptionally, they 
are among the earliest symptoms. Observations have failed to establish an}" 
relation between the seat of the tubercles and the localization of the convul- 
sions. The convulsions may be unilateral, while the tubercles are in both 
hemispheres ; or general, while the tubercles are on one side only. 

The severity and duration of the convulsive attacks, and the frequency 
of their occurrence in tuberculosis of the brain, vary greatly in different 
patients. They have been attributed to softening of the cerebral substance, 
which sometimes occurs immediately around the tubercles, to local conges- 
tions excited by them, and also to serous effusions in the ventricles. The 
convulsions sooner or later end in paralysis or coma. 

Contraction, or tonic spasm of certain muscles, is sometimes observed. 
Its most frequent seat is in the muscles of the back and of one or both of 
the lower extremities. It is a late symptom. It occurs in those cases in 
which there is softening around the tubercles, and usually in the muscles of 
the opposite side,. 

Paralysis is also a late, but not an infrequent, symptom. It is preceded 
by headache, and sometimes, as already stated, by convulsions. Occurring 
as a symptom of tuberculosis of the brain, it is due either to pressure on a 
cranial nerve or to compression and perhaps softening of the cerebral sub- 
stance. The paralysis may be paraplegic, commencing as feebleness of the 
lower extremities, and increasing until it becomes complete, or more or less 
complete, hemiplegia. In paraplegia due to tubercles of the brain the cere- 
bellum is, as a rule, their seat ; while paralysis of one side or of certain mus- 
cles of one side indicates tubercles of the opposite cerebral hemisphere ; but 
there are exceptions. Paralysis of the third cranial nerve gives rise to ptosis 



234 TUBERCULOSIS. 

— of the sixth, to paralysis of the external motor nerves of the eye, and 
therefore to internal strabismus. 

Feebleness or loss of vision, inequality, oscillation, and finally dilatation 
of the pupils, are not infrequent symptoms of tuberculosis of the brain, and 
they possess great diagnostic value. Atrophy of the optic nerve, causing 
amaurosis, sometimes results from tubercles as well as other tumors of the 
brain. Atrophy of this nerve occurs not only when the tubercles are so 
located as to press on the optic tract, in which case the explanation is appa- 
rent, but also, in certain patients, when the tubercles are in other parts of 
the brain. In these last cases it is thought by Brown-Sequard and others 
that the imperfect nutrition of the nerve is due to contraction of its nutrient 
vessels, produced by the tubercles through reflex action. 

In tuberculosis of the brain symptoms pertaining to the respiratory, cir- 
culatory, and digestive systems are either absent or are quite subordinate to 
those of a neuropathic character. Slowness of the pulse, with or without 
intermittence, has sometimes been observed, and it is therefore a symptom of 
some diagnostic value. Toward the close of life both pulse and respiration 
are usually accelerated. Vomiting, constipation, and retraction of the abdo- 
men, which are so common in meningitis, are only occasional symptoms. 

Bronchial Glands. — During the progress of tuberculosis, hyperplasia, 
cheesy degeneration, and softening of various lymphatic glands may occur 
throughout the body, but the bronchial and mesenteric are not only those 
which are most frequently affected, but they are the only glands, unless in 
exceptional instances, which materially increase the danger or give rise to 
special symptoms. These "symptoms either have a mechanical cause — to wit, 
the pressure exerted by the enlarged glands on contiguous parts — or they are 
due to softening of the glands and consecutive inflammation and ulceration. 

The following are the principal symptoms due to compression ; some of 
them are not infrequent, others are rare : Compression of the pulmonary 
veins retards the flow of blood from the lungs to the left auricle, giving rise 
to congestion and, in extreme cases, oedema of the lungs, with sanguineous 
extravasation into the lung-substance, congestion of the right cavities of the 
heart, hepatic veins, and of the systemic capillaries generally. Compression 
of the pneumogastric nerve or of the recurrent laryngeal, which is the motor 
nerve of the laryngeal muscles, modifies the voice and produces a cough 
which is often spasmodic. The cough resembles that of pertussis, and has 
been mistaken for it, but it is not so violent or protracted. The voice, clear 
and natural at first, becomes by degrees hoarse or feeble from deficient inner- 
vation of the laryngeal muscles. 

An enlarged gland or mass of glands lying against the trachea or one of 
the bronchial tubes (this may occur with tubes up to the third or fourth 
division), and pressing its walls inward, obviously obstructs more or less the 
current of air. If there be considerable obstruction, a loud, sonorous rale is 
produced, which is heard distinctly at a distance from the chest, obscuring 
other rales. It is loudest when the patient is agitated, and it sometimes 
intermits. Feeble respiratory murmur, dyspnoea, and a cough are not infre- 
quent in bronchial phthisis. Diminished intensity of the respiratory murmur 
is general or partial, according to the seat of the compression. It has been 
most frequently observed at the summit of the lungs. In certain patients- 
this symptom is not constant, the respiration being for a time feeble and 
then normal. The dyspnoea may be a prominent and distressing symptom, 
the alae nasi dilating, and the inframammary region sinking with each respira- 
tion. The cough which occurs when a gland presses on the trachea or bron- 
chial tube is due to the tracheitis or bronchitis to which the pressure gives 
rise. If ulceration occur at the point of pressure, the cough continues as 



PHYSICAL SIGNS. 235 

long as the ulcer remains. Compression of the large veins within the thorax 
which return blood from the head and upper extremities causes more or less 
congestion of these parts, with, perhaps, transudation of serum in the sub- 
cutaneous connective tissue and within the cranium. Rarely, a softened 
gland by ulceration gives rise to other symptoms than those mentioned — to 
wit, hemorrhage by ulceration into a vessel or pleuritis or pneumonitis if the 
ulceration be toward the lungs. 

Improvement in the condition of the patient affected with bronchial 
phthisis is not unusual. It may be permanent, but in most patients it is 
temporary, so that in a few weeks or months the symptoms are as severe as 
before. The improvement is due to softening and elimination of a gland 
which had given rise to symptoms by its mechanical effect or by the inflam- 
mation which it had excited. 

Physical Signs — From Tahercular Bronchial Glands. — These are absent 
or obscure in the incipient disease when the glands are small, and they are 
most marked in those cases in which the glands are so large as to press on 
the thoracic walls, since they then become the medium for the transmission 
of sounds to the ear. The part of the thorax against which they most fre- 
quently press is the dorsal vertebrae from the first to the sixth, and each 
side of the vertebrae, and less frequently the upper third of the sternum. 
The physical signs are dulness on percussion over the interscapular space, 
and perhaps, though to a less extent, over the upper part of the sternum, 
and bronchial respiration in the same situations. Occasionally a bruit can 
be detected, due to the pressure of a gland on one of the large vessels of the 
chest. 

Lungs. — A cough is one of the earliest and most persistent of the symp- 
toms of pulmonary tuberculosis. It is so rarely absent that those of large 
experience do not meet with more than one or two such cases. It varies in 
severity and frequency. If the tuberculosis be acute and its course rapid, 
the cough, even from its commencement, is frequent, so as to weary the 
patient and deprive him of needed rest. But in ordinary cases — that is, 
when the disease is chronic — it commences gradually, attracting at first little 
attention by its infrequency, but becoming more frequent and painful as the 
malady advances. 

Ordinarily, the cough is dry in the first weeks or months, but it becomes 
looser in the course of the disease, from the greater amount of bronchial 
inflammation. In exceptional instances it has a spasmodic character, like 
that produced by pressure of an enlarged bronchial gland on the pneumo- 
gastric or recurrent laryngeal nerve. This occurs from the accumulation of 
viscid mucus in one or more of the bronchial tubes, usuall}' in dilated por- 
tions of them, from which it is with difficulty expectorated. 

The respiration in pulmonary tuberculosis is accelerated in proportion to 
the degree of tuberculization. Tuberculization of a considerable part of 
both lungs gives rise to dyspnoea, especially when, as is ordinarily the case, 
bronchial, pulmonary, or pleuritic inflammation has supervened. Pneumonitis 
or pleuritis gives rise to the expiratory moan, and as these inflammations, 
when induced by tubercles, are protracted, this symptom may continue for 
weeks or months. 

Patients under the age of six years do not expectorate, or but rarely. 
After this age expectoration is not common in the commencement of pul- 
monary tuberculo.sis. but in the confirmed disease it is a pretty constant 
attendant of the cough. Haemoptysis is also rare under the age of six years, 
and less frecjuent subsequently than in the adult. It is most likely to occur 
in those cases in which there is already passive congestion of the lungs pro- 
duced by the pressure of enlarged bronchial glands in the manner already 



236 TUBERCULOSIS. 

described. Patients old enough to express their sensations, sometimes com- 
plain of fugitive pains under the sternum or between the shoulders. 

In young children the physical signs of incipient pulmonary tuberculosis 
are wanting, or are so obscure as not to be readily recognized. This is due 
to the small size and dissemination of the tubercles. In older children the 
physical signs appear early, and are readily recognized, because, as a rule, 
the tubercles are aggregated, and are more frequently at the apices of the 
lungs, as in the adult, than elsewhere. In the advanced disease, whether in 
infancy or childhood, when inflammation and more or less destruction of the 
lung-substance have occurred, the physical signs, so far from being obscure, 
enable us in most cases, in connection with the history, to make an imme- 
diate and positive diagnosis. 

In young children affected with pulmonary tuberculosis the irregular and 
imperfect expansion of the lungs produces by degrees changes in the shape 
of the thorax which are apparent on inspection. In some, the lungs being 
habitually imperfectly inflated, the obliquity of the ribs is increased, and 
the thorax consequently elongated, while its antero-posterior and transverse 
diameters are diminished. This obviously increases the convexity or arch 
of the diaphragm, so that this muscle sometimes lies against the thoracic 
walls as high as the ninth or even eighth rib. If the costal cartilages are 
yielding, there are anterior flattening of the chest and depression of the 
sternum ; if they are firm on account of the more advanced age, the chest 
remains circular. 

Another shape of the thorax is not infrequent in feeble tubercular chil- 
dren, especially infants, who have suff"ered from repeated attacks of bron- 
chitis. It occurs also in the non-tubercular if the conditions which favor it 
are present. The conditions are, on the one hand, feebleness of the patient, 
with diminished force of respiration and impaired resiliency of the ribs, and 
on the other obstruction by mucus of one or more of the bronchial tubes. 
Occlusion, more or less complete, of a bronchial tube, and consequent 
obstruction to the current of air, produce a corresponding degree of col- 
lapse in the portion of lung to which the tube leads. The parts which col- 
lapse are, in most cases, the lower lobes and the thin anterior margins of the 
upper lobes. This causes lateral depression of the lower ribs, except such 
as are pressed outward by the abdominal viscera and an anterior projection 
of the lower part of the sternum. The shape of the thorax in these cases 
diff'ers from that in rachitis in the fact that the lateral depression does not 
extend to the upper ribs, nor does the upper part of the sternum project. 

Certain precautions should be observed in examining the chest by per- 
cussion and auscultation. The child should sit or recline, with the arms and 
shoulders in the same position on the two sides, and the axis of the trunk 
straight. Inclination of the trunk to either side, raising or depressing a 
shoulder, may produce an appreciable difl"erence in the two sides as regards 
the physical signs. Percussion of the two sides should be practised at the 
same stage of respiration. A slight diff'erence in the degree of resonance 
does not aff"ord proof of disease unless it be observed at diff'erent exami- 
nations ; for in feeble children it often happens that all portions of the lungs 
do not expand alike, so that where we have noticed slight dulness at one 
visit, it may by the next have disappeared, or even at the same visit, if for- 
cible inspirations be excited. 

The physical signs ascertained by palpation, auscultation, and percussion 
are, as in the adult, vocal fremitus, bronchial respiration, bronchophony, and 
dulness on percussion. In those cases in which the tubercles are mainly at 
the apices of the lungs, diminished expansion of the infraclavicular region is 
observed during inspiration, and this part of the thoracic wall is permanently 



BIAGXOSIS. 237 

depressed, so that the clavicles are unusually prominent. If there be 
emphysema, this flattening does not occur or is slight. Dulness on percus- 
sion, though more frequently observed in the infraclavicular region than 
elsewhere, may be present in different isolated places. If pneumonia super- 
vene, the dulness not infrequently extends over a considerable part of one 
lung. The cracked-pot sound is often observed on percussion, but it pos- 
sesses little diagnostic value. It can be produced when there is no pul- 
monary disease by percussion over a bronchus. 

Bronchial respiration and bronchophony are important signs, as indicating 
solidification of the lung, but they do not show whether the solidification be 
tubercular or pneumonic or the two conjoined. This must be determined 
by the history of the case, the extent of surface over which these signs are 
heard, and their persistence. When the tubercles begin to soften and the 
lung-tissue breaks up, moist rales appear, often hoarse and gurgling, obscur- 
ing the bronchial respiration. A cavity in the lung, or pneumothorax, is 
attended by the same physical signs as in the adult. 

Pleura. — Little need be said in reference to the symptoms and physical 
signs of tuberculosis of the pleura, since this affection is in most instances 
associated with tuberculosis of the lungs, and is not distinguishable from it. 
But now and then the pleural tubercles are numerous and large, giving rise 
to symptoms, while those of the lungs are small, few, and without symptoms 
or attended by symptoms which are quite subordinate. Either the costal 
or visceral portion of the pleura may be the seat of tubercles. They are 
developed directly under the pleura or upon its free surface. They may 
occur in the newly-formed connective tissue which results from pleuritis. 
Those located upon the free surface or under the costal pleura rarely soften, 
while those under the visceral pleura sometimes soften and cause ulceration. 
Occasionally numerous aggregated tubercles form a firm continuous layer 
upon the surface of the pleura, preventing, if upon the visceral pleura, full 
expansion of the lung. This may give rise to a degree of dulness on per- 
cussion and feebleness of the respiratory murmur. Ordinarily, however, in 
this form of tuberculosis the symptoms and physical signs, so far as any are 
observed, are due to the pleuritic inflammation which the tubercles excite. 

Stomach and Lttestines. — The sj^mptoms in tuberculosis of the stomach 
and intestines vary according to the seat and stage of the tubercles. 

Tubercles, whether gastric or intestinal, are not at first accompanied by 
symptoms or the symptoms are obscure and ill-defined. Symptoms arise 
when inflammation occurs in the tissues in which the tubercles are imbedded 
or upon which they lie, and through their irritating action. Diarrhoea is one 
of the most common and persistent of the symptoms. The alvine discharges 
are brown and thin, and sometimes, in advanced cases, very offensive. They 
may be streaked with blood which has escaped from the ulcers. Intestinal 
tubercles, developed immediately underneath the peritoneal coat, sometimes 
cause local peritonitis, usually of little extent. This gives rise to circum- 
scribed pain, tenderness, and more or less meteorism. 

Diagnosis. — It is evident from the foregoing description of symptoms 
that the diagnosis of incipient tuberculosis is much more difficult in children 
than adults. Before commencing the examination it is best to learn the 
hereditary tendencies of the family and the history of the patient, especially 
as regards antecedent diseases or debilitating agencies, and the duration of 
the symptoms. 

Early and accurate diagnosis of tuberculosis in the child, as well as in 
the adult, is now rendered possible by the discovery of the tubercle bacillus 
in 1882 by Koch. This bacillus, abounding in the sputum as well as in the 
affected organs of phthisical patients, having a slender rod-like form, having 



238 TUBERCULOSIS. 

a length varying from one-fourth to the entire diameter of the red blood-cor- 
puscles, and susceptible of a peculiar staining by the aniline colors which 
differentiates it from all other bacilli, is, as we have stated above, believed to 
be uniformly present in tuberculosis and absent in other conditions. 

Children with tuberculosis of the lungs expectorate comparatively little, 
but sufficient sputum can probably be obtained in most instances for the 
purpose of diagnosis. The presence of the bacillus indicates clearly the 
tubercular nature of the disease. 

Tuberculosis of the encephalon is diagnosticated with more difficulty than 
that of the thoracic or abdominal organs ; but certain of these organs are in 
most patients tubercular at the same time, and the knowledge of the fact 
that they are affected aids in the diagnosis of the disease of the bram or its 
meninges. Among the symptoms of intracranial tuberculosis which possess 
diagnostic value may be mentioned cephalalgia and more or less fever, with 
exacerbations in the commencement of the disease, and, at a more advanced 
period, strabismus, inequality or irregular action of the pupils, impairment 
of vision, retraction of the head, and convulsive movements or paralysis. 

In certain cases careful observation and discrimination of symptoms are 
requisite in order to determine whether they arise from intracranial tubercles 
or from congestion of the brain caused by obstruction in the venous circu- 
lation by the pressure of enlarged bronchial glands. 

The diagnosis of bronchial phthisis, when the glands are still small, is 
necessarily uncertain, on account of the absence of symptoms. When they 
have increased in size and are so located as to press on the pneumogastric or 
recurrent laryngeal nerve, producing the spasmodic cough already described, 
the differential diagnosis between that disease and pertussis may be made by 
attention to the following facts : Bronchial phthisis occurs singly and is non- 
contagious, while pertussis occurs as an epidemic and with evidences of 
contagion. There are no successive stages — to wit, those of catarrh, par- 
oxysmal cough, and decline — as in that disease, and the cough, though par- 
oxysmal, is short and without whoop or vomiting. 

In feeble children with inherited tubercular diathesis, emaciation, sweats, 
and a chronic cough, with the absence of pulmonary symptoms, should excite 
suspicions that the bronchial glands are involved. The evidence is almost 
conclusive if the cough become paroxysmal and there be a loud, persistent 
tracheal or bronchial rale. 

In certain patients affected with this form of tuberculosis we have seen 
that the prominent symptoms are due to compression of one or more of the 
large vessels in the chest. Compression of these vessels, and consequent 
retarded circulation, may be confidently referred to enlarged bronchial glands, 
since aneurism, carcinomatous or other tumors, which would produce a sim- 
ilar result, are very rare before puberty. Sometimes the diagnosis is rendered 
certain by the physical signs observed by auscultation and percussion over 
the sternum and the interscapular space. The condition of the external 
glands should also be observed, as those of the axilla, neck, and groin. 

The diagnosis of pulmonary, though more readily made than that of 
intracranial and bronchial, tuberculosis is often difficult and uncertain. This 
is in part explained by the fact that the tubercles are so frequently dis- 
seminated, while emaciation and a chronic cough are not infrequent from 
other causes than tubercles. Rachitis, intestinal worms, dentition, simple 
tracheal or bronchial inflammation, may be attended both by a chronic cough 
and emaciation. Caution is therefore requisite in order to avoid a grave error 
in diagnosis. Precipitancy in the diagnosis of doubtful cases is worse than 
indecision, and it is often best to postpone an expression of opinion as to the 
nature of the disease till the case has been observed a few days. 



DIAGNOSIS. 



239 



The significance and importance of the symptoms, physical signs, and 
other facts on which a diagnosis must be based have already been sufficiently 
pointed out. It is difficult- — in fact, in certain cases impossible — to dis- 
criminate by the physical signs between simple cheesy pneumonia and dheesy 
pneumonia which has ended in the formation of tubercles. The patient has 
an attack of catarrhal pneumonia, but instead of absorption of the inflam- 
matory product, cheesy infiltration occurs, and the lung in places becomes 
infiltrated with pus, softens, and breaks down. The patient presents the 
symptoms and physical signs of phthisis. He may recover after a protracted 
sickness or may die. The disease may remain a pneumonia ; but this is a 
condition of the lungs which favors the development of tubercles, and in a 
certain proportion of cases tubercles do form in the last weeks of life. 
Though the differential diagnosis in such cases between cheesy pneumonia 
and tuberculosis supervening on pneumonia is impossible by the physical 
signs, practically the discrimination is unimportant, as the same treatment 
is required. But it is obvious, from the facts now ascertained in reference 
to the tubercle bacillus, that in all cases of doubtful diagnosis the sputum, 
if it can be obtained, should be examined microscopically. If the bacillus 
be present, the diagnosis of tubercular disease may be considered certain. 

Fig. 25. 








^N"^- 



^V 






Z2:^ 



Bacillus tuberculosis (Sternberg). 



Advanced pulmonary tuberculosis, except when it supervenes upon pneu- 
monia, can in most instances be readily diagnosticated by auscultation and 
percussion of the chest. Still, it is to be recollected, as already pointed out, 
that certain of the symptoms and physical signs, which occurring in the adult 
would afi"ord almost positive proof of pulmonary tuberculosis, not infrequently 
have a different origin in children. 

The diagnosis of tubercles in the abdominal organs is facilitated by the 
presence of symptoms which indicate at the same time tuberculosis of the 
lungs. Among the chief diagnostic signs of tuberculosis of the peritoneum 
may be mentioned meteorism and a degree of tenderness on pressure, but 



240 TUBERCULOSIS. 

there is danger of mistaking the tympanitic state of the intestines common 
in ill-nourished infants and the rachitic, or the fulness due to an enlarged 
spleen or liver, for that occasioned by peritoneal tuberculization, and vice 
versa. The history of the case and a careful examination of accompanying 
symptoms and the shape and feel of the abdomen usually suffice to establish 
the diagnosis. In simple gaseous distension of the abdomen there is an 
absence of the symptoms, general and local, which attend tuberculosis ; 
rachitis occurs at an earlier age than peritoneal tuberculosis, and digital 
examination, aided by percussion, enables us to diagnosticate enlargement of 
the liver or spleen. 

Tubercular enlargement of the mesenteric glands cannot be positively 
diagnosticated when they are small. When they have attained such a size 
that they can be felt through the abdominal walls, palpation, in connection 
with the history and symptoms of tuberculosis, suffices to establish the diag- 
nosis. Enlarged and tubercular mesenteric glands can be diagnosticated from 
other tumors by the fact that they are tender on pressure and occupy the 
umbilical region. Fecal accumulations, from which they are to be diagnos- 
ticated, are located in the iliac or lumbar region. Gastro-intestinal tuber- 
culosis cannot be positively diagnosticated. Protracted diarrhoea or frequent 
attacks of diarrhoea, not readily controlled by medicine and occurring in 
tubercular cases, are probably associated with intestinal ulceration. 

Prognosis. — It has long been the belief in the profession, as well as among 
the laity, that tuberculosis is in the end, with few exceptions, fatal, whatever 
remedial measures are employed, and that, therefore, remedies may ameliorate 
symptoms, but do not change the result. But since attention has been directed 
to this subject a sufficient number of observations have been made to show that 
tuberculosis at an early stage can in a considerable number of cases be cured 
or rendered latent. The late Professor Austin Flint, in his treatise on Phthisis, 
published in 1875, stated that of 670 phthisical cases which came under his 
observation, he ascertained by auscultation and percussion that the disease 
had been cured in 44 and was non-progressive in 31 others. But the most 
convincing proof of the curability of tuberculosis is furnished by the post- 
mortem examination of those who have died of other diseases. A cretaceous 
or fibroid state of the apex of the lung, without tubercles elsewhere, may be 
regarded as certain evidence of arrested tuberculosis. Now, two of the 
curators of large New York hospitals inform me that they frequently find 
cretaceous or fibroid degeneration at the apex of the lung, without tubercles 
elsewhere, in the autopsies in these institutions. One of these gentlemen, 
whose examinations are in the dead-house of Bellevue Hospital, states that 
this evidence of arrested tuberculosis is present in at least one-fourth of the 
cadavers which he examines, and the Bellevue Hospital patients come from 
the most crowded and insalubrious tenement-houses of the city, and have led 
a life of poverty and privation, and frequently of dissipation. The London 
Lancet (September 22, 1888) states that M. Vibert has examined the records 
of the necropsies in the Paris Morgue, and that in 131 subjects whose death 
had been sudden from violence or acute diseases, the lesions of pulmonary 
tuberculosis were present in 25, and in 17 of these the tubercles had under- 
gone the cretaceous or fibroid change, and were practically cured. It is cer- 
tain, therefore, that tuberculosis of the adult in its commencement, and when 
affecting only a small portion of the lung, is often cured or rendered per- 
manently latent. 

It is now known that ordinary serum circulating in the blood-vessels 
possesses marked germicidal properties, and therefore measures which benefit 
the general health and improve the quality of this important constituent of 
the blood have a curative effect as reorards tuberculosis. The tubercle bacillus 



PROPHYLAXIS. 241 

is an irritant to the tissues, and in cases which are cured or rendered latent it 
becomes surrounded by dense tissue which in time undergoes the cretaceous 
or fibroid degeneration. The bacilli in the interior of the mass may retain 
their vitality for an indefinite time, but, being encapsulated, they do no harm. 
There can be no doubt that many adults have local tuberculosis, and are cured 
by improvement in their general health and in the quality of their blood, 
without suspecting that they have had this disease. In young children, 
especially in infants, tubercles are frequently disseminated in the organs, 
and recovery under such circumstances must be impossible or rare ; but local 
tuberculosis or tuberculosis limited to certain glands, as the bronchial, is not 
unusual in childhood, and this form of the tubercular disease may be cured 
by itieasures which improve the general health. 

Hospital statistics show that the average duration of the disease is from 
three to seven months. Under favorable circumstances it is more protracted, 
even to two or three years. Those succumb soonest who inherit a strongly- 
marked tubercular diathesis, live in damp, dark, and ill-ventilated apartments, 
and whose diet is scanty or of poor quality. Therefore in the poor quarters 
of the city tuberculosis presents a worse form and pursues a more rapid course 
than among families in better circumstances. 

Favorable prognostic signs are absence of tubercular diathesis, good 
appetite and general health, with little emaciation, infrequency of cough, with 
respiration, pulse, and temperature nearly normal. Such symptoms may 
afibrd hope of recovery with judicious regimenal and therapeutic measures. 
On the other hand, if the symptoms be grave death is inevitable, unless in 
bronchial phthisis, in which, even when there is considerable urgency of 
symptoms, the offending gland is sometimes eliminated by softening and 
ulceration, and the patient improves temporarily, if he do not ultimately 
recover. Complete and permanent recovery is, however, quite exceptional in 
bronchial phthisis, as it is in other forms of the disease. As Liebermeister 
has said, recovery in any form of tuberculosis is impossible except in incipient 
and very limited forms of the disease. 

Death in tuberculosis of children may occur from exhaustion induced by 
the general disease or from the local eff"ects of the tubercles. Thus, in 
intracranial tuberculosis it may result from meningitis ending in convulsions 
and coma ; in pulmonary tuberculosis, from dyspnoea, though more frequently 
from exhaustion ; in that of the bronchial glands, from dyspnoea or hemor- 
rhage ; in that of the abdominal organs, from peritonitis or protracted diar- 
rhoea. 

Prophylaxis. — Since tuberculosis originates in so many different ways, 
measures designed to prevent this disease have a wide range. Precau- 
tionary measures are especially required in the nursing of the tuberculous 
patient. His sputum should always be received in a cup or spittoon contain- 
ing a disinfectant liquid, and this vessel when emptied should be cleansed 
with boiling wate-r or a disinfectant. Sputum should never be received upon 
a handkerchief or^loth and allowed to dry. Towels and handkerchiefs should 
be moist when used, and immediately afterward placed in boiling water or a 
disinfectant. We have seen what disastrous results occur from the dried 
sputum. Whatever may be said of the innocuousness of the breath of the 
phthisical patient, based on the supposition that the tubercle bacillus has so 
great a specific gravity in its moist state that it is not exhaled in ordinary 
respiration, nevertheless the sad experience of the midwife related in a 
foregoing page should teach us to avoid his breath, so far as is com- 
patible with proper ministrations to him. The floors and walls of his 
apartment .should occasionally be washed with a disinfectant fluid, and 
the bedding, clothing, rugs, and mats should never be shaken in the apart- 

16 



242 TUBERCULOSIS. 

ment, but outside the house. Ventilation of the apartment should be allowed 
to the full extent compatible with the safety of the patient. The remedies 
which we will hereafter recommend in the treatment of the patient are 
destructive to the bacillus, and therefore whenever employed have also a 
prophylactic action. 

No physician who has read in the medical journals of the last decade the 
many reports of cases in which milk has been the vehicle of pathogenic 
organisms has failed to see the urgent need of obtaining this indispensable 
article from healthy dairies. Families should insist on the inspection at 
regular intervals of the dairies that furnish them milk, and the exclusion of 
such animals as exhibit the least sickness. Moreover, no one with a chronic 
cough should be employed in milking or in the subsequent handling of the 
milk. But with the utmost endeavor, on the part of families living at a dis- 
tance, to obtain milk free from impurities, no one can state positively that it 
will not sooner or later contain pathogenic organisms, as those of diphtheria, 
scarlet fever, typhoid fever, or tuberculosis, so many and unsuspected are the 
modes of infection. Fortunately, heat at or near the boiling-point is an 
effectual sterilizing agent, and it can be employed without diminishing the 
nutritive properties of milk or rendering it more indigestible. I do not for- 
get the interesting experiments which have been made to determine the ten- 
acity of life of the tubercle bacillus when subjected to heat and cold. In 
experiments made it is said to outlive most of the microbes associated with 
it. Schill and Fischer state that dried and pulverized tubercular matter not 
subjected to treatment retains its virulence six months, and Pietro states that 
tubercular sputum well dried and maintained at 77° retains its virulence nine 
or ten months. But what concerns us most at present is the remarkable 
statement made by Max Yoelsch (^Centralb. filr Miu. J!/} 6?., June 30, 1888), 
that twice boiling does not entirely destroy the virulence of the tubercle 
bacillus. I habitually direct that the morning supply of milk designed for 
children shall be immediately placed in a steamer and subjected for two 
hours to a temperature of 190° to 200°. No pathogenic microbe can prob- 
ably survive if subjected so long a time to so high a degree of heat. The 
flesh of the tubercular animal, which it is believed is often purchased by 
unsuspecting families, evidently requires similar treatment — that is, thorough 
cooking — in order to be rendered innocuous. A competent meat inspector 
should be employed at each slaughter-house, and all diseased meats be 
rejected; but in the present management of the meat market the only 
sure method of preventing the presence of living and active bacilli in 
the meat foods appears to be by thorough cooking. 

Outdoor life, residence in elevated localities, where the air is not only 
pure but rarefied, the occupancy of sunlit and well-ventilated rooms, the 
avoidance of rooms or localities where the air is contaminated by the pres- 
ence of others, as in crowded schools or factories, or by unwholesome occu- 
pations, and all measures which promote the appetite and general health, are 
prophylactic, as they are also to a certain extent curative, of tuberculosis. 
It is evident, from what has been stated above, that caseous substance occur- 
ring in any part of the system, inasmuch as it sustains a close causal relation 
to tuberculosis, should, if practicable, be removed by surgical measures. 
Moreover, since cheesy degeneration results for the most part from inflam- 
mations occurring in the scrofulous, measures designed to prevent or cure 
such inflammations or to cure scrofula have a prophylactic effect as regards 
tuberculosis. The strumous child should be watched with great care, and 
such measures be employed as are calculated to invigorate his system. He 
should receive antistrumous treiitment, both hygienic and medicinal. Espe- 
cially should glandular hyperplasia and the products of inflammation, whether 



TREATMENT. 243 

occurring in the lungs or elsewhere, be, if possible, removed before caseation 
occurs. For this purpose the old remedies, like cod-liver oil and syrup of 
the iodide of iron, given internally, and for hyperplasia of the subcutaneous 
glands ointments like iodide of potassium in lanolin, may be advantageously 
employed. Finally, one having an abrasion or sore of the cutaneous or 
mucous surface, or catarrh of the air-passages, as indicated by discharge 
from the nostrils, sore throat, or a cough, should not attend as nurse or 
otherwise a phthisical patient until his local ailment is cured, since the tuber- 
cle bacillus is believed to enter the system more readily through a diseased 
than a healthy surface. 

Treatment. — The indications of treatment are twofold : first, to invig- 
orate the system in every possible way, so that the organs and tissues are in 
a better condition to resist the bacillus and the serum to antagonize and 
destroy it ; and, secondly, the employment of medicinal agents, if such can 
be found, which are destructive to the bacillus and safe to the patient. 

Measures designed to improve the general health must be chiefly hygienic, 
and are described in all the text-books. The diet should consist of milk, the 
meat preparations, and farinaceous substances, prepared in such a way that 
they afford the maximum amount of nutriment and are easily digested. If 
the digestion be poor, peptonized food may be advantageously employed, and 
pepsin may be taken with the food. In 1881-82, Debove recommended 
gavage or forced feeding of consumptives through a flexible rubber tube 
having a funnel attachment, the tube being introduced into the stomach. He 
employed meat preparations, with pepsin. In the Medical News ^ October 1, 
1887, Dr. S. Solis-Cohen of Philadelphia also recommended gavage in the 
treatment of phthisis. A quart of milk, two tablespoonfuls of beef powder, 
three eggs, fifteen grains of scale pepsin, and thirty drops of dilute muriatic 
acid were warmed and administered twice daily through a stomach-tube, a 
patient eating what he wished in the interval. Gravage has been employed 
by certain European physicians in the treatment of children suff"ering from 
various forms of innutrition, and it seems probable that tubercular patients 
may be benefited by it in some instances. In the ordinary mode of feeding 
the predigested foods can often be used with benefit by consumptives, inas- 
much as they have, for the most part, feeble digestion. 

As regards the hygienic measures designed to arrest tuberculosis, the 
most important, next to the use of proper food and the employment of such 
aids to nutrition as cod-liver oil and the alcoholic preparations, is outdoor life, 
and, if possible, in localities having a high altitude. The late Professor Flint, 
in examining the records of 62 cases of arrested phthisis which came under 
his observation, ascertained that the principal agent in affecting this result 
was exercise in the open air. He therefore strongly recommended this mode 
of life to consumptives, and also constant ventilation of their sleeping apart- 
ments, even in the winter season, the danger of taking cold being averted by 
maintaining sufiicient warmth of air by a fire. Dr. James Blake has also 
reported instances of recovery of phthisical patients who lived during the 
five or six months of the dry season in the open air upon the Coast Range 
of mountains in California at an altitude of 3000 to 5000 feet. These 
patients were in the open air night and day, without even the protection 
of tents. 

Residence at a High Altitude. — The London Lancet, May 26, 1888, con- 
tains the abstract of a paper read before the Medico-Chirurgical Society of 
London by Dr. Williams, recommending residence at a high altitude as an 
efficient means of checking the progress of tuberculosis. He states that of 
141 patients who had employed the high-altitude treatment, 14.13 per cent, 
were completely cured, 29.78 per cent, were much benefited, 11.34 per cent. 



244 TUBERCULOSIS. 

were more or less benefited, and 17.02 per cent., including 13.47 per cent, 
who died, continued to grow worse. Drs. Quain and Pollock, in discussing 
this paper, expressed the opinion that consumptiv^es who improve at a high 
altitude improve equally with the same treatment at lower elevations ; in 
other words, that residence at a high altitude does not influence the result. 
Brehmer, on the other hand, believes that the inhabitants have immunity 
from tuberculosis at an altitude of 1500 feet in Germany, of 4500 to 5000 
feet in Switzerland, and 10,000 to 15,000 feet at the equator {Die Theraple 
Chronische Lungenheschwerden.^ Wiesb., 1887). The most apparent and notable 
peculiarity in the air at high elevations, apart from its purity, is its rarefac- 
tion. At an altitude of 9000 feet above the level of the sea it is said, from 
observations made, that the air is so rarefied that three times the usual 
exercise of the lungs is required to meet the demands of the system. Dr. 
Mays states in a paper published in the Medical News^ November 27, 1886, 
that the Quichua Indians, on the lofty plateaus of Peru, constantly breath- 
ing a rarefied air, " acquire enormous dimensions " of the chest, due to an 
increase in the size, and perhaps number, of the air-cells. More numerous 
and more exact observations are required in order to determine whether or to 
what extent residence at a high altitude is beneficial to consumptives, and, 
if it exerts a controlling effect on the disease, whether this result is due to 
the increased pulmonary expansion and activity or to other causes. Certainly, 
from observations already made, we are justified in recommending outdoor 
life in a mild and equable climate, and also residence at high elevations if the 
cold is not too severe. 

Residence in the Evergreen Forests and' the Use of Turpentine. — In an 
interesting paper read before one of the societies, and subsequently pub- 
lished. Dr. A. L. Loomis states his belief that the terebinthinate vapors in 
the evergreen forests possess healing properties for consumptives. He quotes 
the statement of Ringer that turpentine employed as a medicine enters the 
blood, and may be detected in the breath, the perspiration, and in an altered 
form in the urine of the patient. The presence of the vapor of turpentine 
in the pine forest. Dr. Loomis remarks, cannot be doubted, and its " local and 
constitutional effects." he adds, " are those of a powerful germicide as well as 
stimulant." Dr. Loomis quotes the opinion of Mr. Kingsett that turpentine, 
during its oxidation, evolves the peroxide of hydrogen, and therefore by the 
" oxidation of the terebinthinates there is produced in extensive pine forests 
an almost illimitable amount of peroxide of hydrogen, which renders tho 
atmospheres of such forests antiseptic." He believes that the peroxide of 
hydrogen so abundantly produced in pine forests " successfully arrests putre- 
factive processes and septic poisoning," and therefore he recommends resi- 
dence in the pine forests as one of the most efficient means of relieving the 
symptoms of tuberculosis and retarding the progress of this fatal malady. 
At high altitudes the coniferous or evergreen trees usually predominate, and 
if the views of Professor Loomis be substantiated by future investigations, 
it may be that the benefit believed to be obtained by consumptives at high 
elevations is partly due to the exhalations from these trees. 

The bacteriologists who have cultivated the tubercle bacillus, and 
observed the action upon it of the various agents which have been employed 
and extolled by clinical observers, state that most of these agents do not 
penetrate the tubercular mass — that while they may destroy the superficial 
bacilli, they do not affect those more deeply seated, and therefore fail to 
arrest the disease. But turpentine and its derivatives appear to penetrate 
the tissues as deeply as almost any other agent, and therefore, if they are 
sufficiently antiseptic and not too irritating, we may expect good results 
from their judicious use. But it is probable that they are less efiicient as 



TREATMENT. 245 

germicides than some of the other agents which can be safely employed, and 
therefore should be recommended only as adjuvants, or as remedies which 
may give some relief to the catarrhal and other symptoms without exerting 
any marked antiseptic action. Hohnfeld states that he applied oil of turpen- 
tine to fresh colonies of the micrococcus prodigiosus and staphylococcus 
aureus, and that it exerted little destructive or retarding effect on these 
micro-organisms.^ These experiments would lead us to distrust the germi- 
cide action of turpentine and the terebinthinate preparations in tuberculosis, 
for the tubercle bacillus is tenacious of life beyond most other microbes. 
But the alleged good results of teaspoonful doses of the oil of turpentine in 
that other microbic disease, diphtheria, certainly justify the experimental 
use of the agent in tuberculosis. 

Terebene, produced by the action of gaseous hydrochloric acid on tur- 
pentine, has been prescribed in tuberculosis and chronic bronchial catarrhs, 
with some apparent benefit. An adult should take ten, increased to twenty, 
drops three times daily. A child can take a dose proportionate to the age. 
The following formula has been recommended : 

R. Terebene, 5iv; 

Pulv. acacise, 3iij ; 

Aquse, .^ij ; 

Syr. zingiberis, ^j. M. 

Dose : One teaspoonful three times daily for an adult ; a dose proportionate to the age 
for children. 

Terebene can also be employed in inhalation from Robinson's inhaler, or, 
properly diluted, from the hand- or steam-atomizer. It has been adminis- 
tered in ten-drop doses to some of the adult consumptives in my wards in the 
Charity Hospital, and the resident physician who had charge of these cases 
writes me as follows : " I am satisfied that in nearly all cases of dyspnoea it 
is of value. In some it affords marked relief, and I have had patients tell 
me that it gave the most relief of anything. Others say that it afforded 
some relief. It makes expectoration in some patients markedly more easy 
and the sputum much thinner ; in others the effect is only slight or moderate." 
It probably aids in relieving the catarrh which accompanies tuberculosis. 

Hot-air Inhalations. — Halter states that workers in a limekiln, breathing 
dry air at a temperature of 122° to 156° F., were exempt from phthisis dur- 
ing a period of fifteen years in a locality where this disease was common. 
He also states that the most favorable temperature for the growth of the 
bacilli is 98.6° to 104° F., and that a temperature of 105.8° destroys them. 
Moreover, his experiments have shown him that the inhalation of dry air at 
a temperature of 248° to 256° raises the temperature of the expired air to 
about 109.7° — a degree of heat which, he says, is fatal to the bacillus.^ Dr. 
E. Krull states that for more than two years he has treated consumptives 
with the inhalation of hot air heated to 132° F., and that this raised the 
temperature of the expired air to not less than 107.6°, and incipient cases 
seemed to derive benefit from this treatment. Dr. Weigert of Berlin has 
constructed an apparatus for the inhalation of hot air which was employed for 
a time in the wards of Charity Hospital, but it did not seem to give as much 
relief as the antiseptic inhalations which have been used by the same patients. 

Dr. Trudeau of Saranac Lake prescribed the hot-air treatment in four cases 
four hours each day, the temperature of the inhaled air being 392° F. The first 
and second patients improved slightly at first, but refused the treatment, the 
one after one month, and the other after six weeks. The third patient was 

^ Fortschrittt der Mediciv, October 1, 1887. 

^ Berliner klinische Wochenschrift, September 3, 1888. 



246 TUBERCULOSIS. 

treated three months without the least appreciable effect. The fourth patient 
was treated four months, with manifest improvement in her physical signs 
and general health, but no more improvement than frequently occurs from 
any new mode of treatment. In all the cases the sputum was examined 
before, during, and after the treatment, and in every examination the tuber- 
cle bacillus was present. The result claimed for the hot-air treatment had 
not been obtained — that is, the destruction of the bacilli ; and if they are 
not destroyed in the sputum, certainly they are not in the tissue of the lung. 
Therefore there can be little doubt that the hot-air inhalations, so far from 
coming into general use, will be discarded, not only because they are 
unpleasant to the patient, but are inefficient. There is always a large amount 
of residual air in the alveoli, and there can be little doubt that in the hot-air 
inhalations the air in the alveoli and terminal bronchial tubes never attains 
the elevation of temperature of the air that is inhaled, nor of that which 
is exhaled. Moreover, as we have seen, the tubercle bacillus resists the 
destructive action of high temperature. It is said to retain its vitality 
in liquids which have been twice heated to the boiling-point. 

Creasote. — Of the many medicines which have been recently employed 
in the treatment of tuberculosis, creasote appears to have given more gen- 
eral satisfaction than any other. I am informed that the late Dr. Cammann, 
the inventor of the binaural stethoscope, employed it twenty years ago in 
the treatment of tuberculosis, but it was seldom prescribed for this disease 
until within the last decade. In the Berliner Jdmische Wochenschriff, Jnlj 
20, 1886, Von Brunn states that he has treated 1700 phthisical patients in 
the last eight years with creasote, giving to adults not less than six to eight 
drops in twenty-four hours. He employed it in solution with tincture of 
gentian and wine, and believes that he obtained good results, especially in 
acute unilateral cases. Professor Sommerbrodt states^ that he employed 
creasote in about 5000 phthisical cases during the preceding nine years. x\t 
first he used Bouchard's solution of creasote, and afterward gelatin capsules, 
each containing three-fourths of a grain of creasote and three minims of the 
balsam of Tolu. The amount of creasote administered daily to the patients 
who were adults was increased gradually from one capsule to not less than 
nine. As many as 600 to 2000 capsules were given to each patient without 
a break. In many cases the improvement was marked, not only in the 
symptoms and in the general health, but also in the physical signs. He 
believes that he has cured cases by insisting on a continuance of the treat- 
ment. To show the good effect of creasote, he cites the case of a student 
of sixteen years, with tuberculosis of the right lung, who took three cap- 
sules three times daily, or about seven and a half grains per diem. His 
cough abated, his weight increased six pounds in two months, his expectora- 
tion had ceased. Instead of the dull percussion sound over the apex of the 
right lung, only a slight rhonchus was observed, and his general health had 
greatly improved. 

Many others who have employed creasote during the last two or three 
years, both in this country and in Europe, report favorable results. Striim- 
pell says that it produces no ill effects, and in large doses it frequently causes 
improvement in such symptoms as the cough, expectoration, and appetite, but 
he doubts whether it exerts any marked curative effect upon the disease. It 
has been employed during the last year in Charity Hospital, and the resident 
physician who had charge of the ward in which it was used writes to me 
that it " seems to possess some staying influence over the progress of the 
disease." In the New York Foundling Asylum creasote in cod-liver oil has 
been administered during the last year to the few phthisical patients under 

^ Medical Chronicle, July, 1887. 



TREATMENT. 247 

treatment, in doses of one drop three or four times daily to children of three 
or four years, and Dr. Lynde, the resident physician, thinks that it has been 
the most useful of the remedies employed. 

During the past year I have prescribed creasote for internal use in the 
following formula : 

R. Creasoti (Morson's), 
Spirit! chloroformi, 
Alcoholis, da. ^ss, M. 

Dose for an adult, nine drops three times daily in half a teacupful of water 
containing a tablespoonful of brandy or two tablespoonfuls of wine. The nine 
drops of the mixture, containing three of the creasote, have been increased to 
twelve drops, or four of creasote, and thus far in my practice patients believe 
that they have been benefited by this remedy, and have desired to continue 
it. At the same time, in some instances I have recommended the inhalation 
of ten or fifteen drops of the same mixture from Robinson's inhaler. This 
dose of creasote, three or four drops, may seem large, but it is tolerated when 
sufficiently diluted, though it may be best to commence with a smaller quan- 
tity. Children should of course take doses proportionate to the age, the frac- 
tional part of a drop being sufficient for infants. Creasote has also been 
injected into the tubercular lung through the chest-walls by several physicians, 
a syringe provided with a long and delicate needle being used. Rosenbusch 
injected eight drops of a 3 per cent, solution of creasote in almond oil in two 
places at the seat of the disease, or sixteen drops in all. The result was a 
marked diminution of the cough, the SAveats, the amount of sputum, and, in 
recent cases, an increase in weight. The beech creasote was used, and the 
skin and apparatus were first sterilized by an antiseptic lotion. When the 
instrument was not introduced deeply enough, a sharp, pleuritic pain some- 
times occurred, but it soon abated. Creasote appears to be the most valuable 
of the recent remedies recommended for tuberculosis, but in order to deter- 
mine its exact value, the proper mode of employing it, and the size and fre- 
quency of the dose, more extended observations are required. Frantzel says 
that experiments have shown that this substance is inimical to the growth of 
the bacillus when mingled in minute quantity with a gelatin culture-medium, 
and on this fact is based its internal administration. When it is injected into 
the lungs through the chest-walls, Dr. E. Gr. Janeway of New York believes 
that it is very important that the almond oil or other vehicle employed should 
be first sterilized. 

In the present state of our knowledge of the use of antiseptics in the 
treatment of tuberculosis creasote is the one which is most deserving of con- 
fidence and employment. In New York City, in the present epidemic of 
measles, in cases of protracted broncho-pneumonia with emaciation, the 
symptoms indicating the probability of cheesy degeneration and commencing 
tuberculosis, the patients being young children, I am prescribing the hourly 
inhalation of the vapor of creasote, one part to ten or fifteen of terebene, 
fifteen to twenty-five minims of the mixture being dropped on blotting-paper 
in the bottom of a teacup. Children willingly inhale this vapor five or ten 
minutes at a time, with some apparent relief of symptoms. At the same 
time, I employ creasote internally if marked symptoms of tuberculosis appear. 
The following prescription has been considerably employed , 

R. Creasote, r(\J^\ ; 

Tine, gentian., '^'^^'i 

Alcohol, .^x ; 

Tokay or Malaga wine, 5 v. Misce. 

Dose : One teaspoonful three times daily to an adult ; a dose proportionate to the age 
for a child. 



248 TUBERCULOSIS. 

Iodoform. — This agent, dissolved in ether and inhaled, has been recom- 
mended. It apparently gives some relief to the cough, and possibly to other 
symptoms, but the belief that it is destructive to the bacillus has been shown 
to be fallacious by the experiments of Roosing, who inoculated the eye of a 
rabbit with tubercular matter mixed with iodoform, and the iodoform did not 
prevent or retard, but apparently accelerated, the development of tubercle at 
the point of inoculation by its irritating effect upon the eye/ Iodoform can- 
not, therefore, be recommended as a curative agent in tuberculosis. 

Biniodide of Mercury., Corrosive Sid)liinate. — Miguel and Rueff employed 
a solution of biniodide of mercury, 1 part to 40,000, as a germicide spray in 
tuberculosis. They state that of 27 patients treated by this spray, 19 improved, 
and the remaining 8 were neither made better nor worse. It is unfortunate 
that the results of treatment by the biniodide, as observed by these physicians, 
were not stated more in detail. If they relied entirely on the opinions of the 
patients, they may have been deceived, for patients with chronic diseases 
often believe for a time that they are benefited by new modes of treatment 
when there is no actual improvement. 

The fact that corrosive sublimate, employed internally and locally in the 
treatment of diphtheria, has the confidence of the profession as an efficient 
germicide suggests its use in the treatment of other microbic maladies. 
Moreover, its use in diphtheria has shown us what doses of this powerful 
agent can be safely prescribed. I am not aware that corrosive sublimate has 
been employed internally in the treatment of tubercular patients, but it has 
been used as a spray. In the Charity Hospital several of the patients inhaled 
from the atomizer one teaspoonful of an aqueous solution of corrosive subli- 
mate, two grains to the pint, every three to six hours, and both the patients 
and house-physicians believe that it acts beneficially in relieving symptoms, 
especially the cough. It cannot be doubted that the spray employed as often 
as every third hour disinfects the sputum to a great extent, and destroys the 
bacilli upon the surface of the larynx, bronchial tubes, and in the alveoli, but 
whether benefit may accrue to consumptives from its internal use we have not 
sufficient data for determining. 

Another medicine which has been considerably employed in Europe, and 
in regard to which opposite opinions are expressed, is hydrofluoric acid. 
MM. Seller and Garcin of Paris detailed the results of their use of this agent 
in a paper published in 1887 in the BidJetin de r Academic de Medecine. 
They state that of 100 tubercular patients treated by hydrofluoric acid, 35 
were cured, 41 exhibited more or less improvement in symptoms, 14 were 
not benefited, and 10 died. They state that in the favorable cases rapid 
improvement was observed in the symptoms, such as the fever, night-sweats, 
dyspnoea, and expectoration. Giacomi of Berne employed a mixture of 100 
grammes of hydrofluoric acid with 300 grammes of water in a vessel over a 
spirit-lamp : 8 patients inhaled the vapor one hour each day. In 1 marked 
relief occurred ; in another some temporary improvement took place as regards 
the appetite and dyspnoea, but in the remaining 6 the result was negative. 
No discomfort resulted from the inhalation, though from the well-known action 
of hydrofluoric acid the window-panes became more or less opaque. Gager 
has treated 17 cases with the vapor of hydrofluoric acid with the following 
result : In 5 the bacilli disappeared from the sputum and the auscultatory 
signs improved in a marked degree ; in 7 some improvement in the physical 
signs occurred ; in 12 the weight increased ; in 5 cases no result.^ Grancher 
and Chautard experimented with hydrofluoric acid on rabbits, and they 
express the opinion that the vapor of this agent does not penetrate sufficiently 

^ -London Lancet, January 21, 1888. 

^ Deutsche medicinishe Wochenschrift, 1888, p. 597. 



TBEA TMENT. 249 

to destroy bacilli in the depth of the tissues. Trudeau states that the vapor 
of hydrofluoric acid is efficient as an antiseptic, and seems to possess greater 
penetrability than the ordinary antiseptic sprays ; but it can only destroy 
those bacilli with which the inhaled vapor comes in contact ; therefore, the 
bacilli imbedded in the tubercular nodules and the tissues escape.^ Professor 
Jaccoud inoculated guinea-pigs with tubercular sputum which had been sub- 
jected to the action of hydrofluoric acid, and produced tuberculosis with this 
sputum as certainly as with sputum not thus treated. From these experi- 
ments and others performed under his direction Jaccoud believes that the 
vapor of hydrofluoric acid, employed in any safe manner, does not destroy 
the tubercle bacillus or notably diminish its virulence.'-^ Therefore, the good 
effects from the use of this medicine claimed for it by those who first employed 
it have not been realized in the practice of more recent observers, so that we 
cannot recommend its employment in the place of remedies which have pro- 
duced favorable results. 

Rectal Injections of Sulphuretted Hydrogen. — This treatment was first 
employed by Dr. Bergeon of Lyons, and, being highly recommended by him, 
has been prescribed by many physicians in Europe and America. Its real 
value has now been apparently fully ascertained. The history of its use is 
instructive, since it shows how a mode of treatment which is inert may gain 
the confidence of intelligent physicians. The Biitish Medical Joiirned^ May 
21, 1887, states that Dr. S. Cayhill of the Isle of Wight has employed Ber- 
geon's treatment in private and hospital practice with the most encouraging 
results. He believes it is the greatest advance ever made in the therapeutics 
of pulmonary diseases. Dr. Henry Bennet also notices favorably Bergeon' s 
treatment in the same journal for December, 1886. The late Dr. Bruen of the 
University of Pennsylvania treated 25 cases by Bergeon's method, employing 
twice daily from three quarts to a gallon of the gas slowly introduced. In nearly 
all the cases the night-sweats ceased, the cough, expectoration, and frequency 
of the pulse diminished, and the temperature fell half a degree to one degree. 
On the other hand, Drs. Shattuck and Jackson of Boston employed Ber- 
geon's treatment in 7 cases. No odor of the gas could be detected in the 
breath of these patients after its use, and paper moistened with a solution of 
the acetate of lead was not blackened when held before the mouth. The only 
result which might be attributed to the enemata was some diminution in the 
expectoration. Professor Austin Flint has made experiments in order to 
determine whether sulphuretted hydrogen introduced per rectum or by sub- 
cutaneous injection enters the lungs. He tested the expired air by holding 
before the mouth white filter-paper, moistened with a solution of acetate of 
lead. He ascertained that sulphuretted hydrogen was not exhaled at all, or 
was exhaled in small quantity and for a period not exceeding three minutes. 
The presumption is, therefore, strong that sulphuretted hydrogen employed 
per rectum or subcutaneously in some instances does not enter the lungs, and 
in other instances enters them in small quantity and is quickly expelled. 
Dr. G-rauer placed cultures of the tubercle bacillus as well as of other patho- 
genic germs in test-tubes, and subjected them to a current of sulphuretted 
hydrogen from two hours to a longer time, and yet their vitality was pre- 
served, so that successful inoculations or cultures were produced. Dr. E. C. 
Trudeau of Saranac Lake says that in May, 1887, a tube containing a pure 
culture of the tubercle bacillus was subjected for thirty minutes to a stream 
of undiluted sulphuretted hydrogen made from sulphide of iron and sulphuric 
acid. The conducting tube was pushed through the cotton and held within 
half an inch of the coagulated serum, and the jet of gas allowed to play freely 
on the bacilli upon its surface. The entire mass soon became so blackened 
^ Medical Ncws, May 5, 1888. ^ London Lancet, November 10, 1888. 



250 TUBERCULOSIS. 

by the action of the sulphur as to resemble dark-gray paint. The microbes 
thus treated were then mixed with the sterilized water and injected into the 
pleural cavites of two full-grown rabbits. These animals were then placed 
in a large box, well fed, and kept under a shed in the open air all summer. 
On October 19th, one hundred and sixty-two days after the inoculation, both 
rabbits died within two hours of each other, and both were found to have 
cheesy bronchial glands and advanced pulmonary tuberculosis. The benefit, 
therefore, supposed by some to be derived from Bergeon's treatment is prob- 
ably due to hygienic measures. 

Sulphurous Acid. — Dr. Dariex, in a monograph published in the Bulletin 
general de Therapeutique., February 29, 1888, states that Galen, in the second 
century, recommended the sulphurous air of volcanoes for consumptives. In 
recent times attention has been drawn to the beneficial eifects of the inhala- 
tion of sulphurous vapors in tuberculosis by M. Salland, an army surgeon. 
A sergeant having this disease, which was progressing notwithstanding active 
medication, was placed in charge of the rooms in the barracks in which sul- 
phur was burned for disinfecting purposes. This service obliged him to pass 
nine hours each day in a sulphurous atmosphere. At the end of sixty-five 
days he was cured. M. Auriol, having observed the good effect of the inhala- 
tion of sulphurous acid upon certain consumptives whose occupation com- 
pelled them to live in an atmosphere charged with this gas, fitted up a room 
for the treatment of this disease. The flowers of sulphur, slightly moistened 
with alcohol, was burnt in the corner of the room. Soon the patient began 
to have paroxysms of coughing, but he did not leave the room until moistened 
test-paper began to redden ; if the respiration was much oppressed, he left the 
room sooner or the window was opened. In order to render the vapor less 
irritating and the paroxysms of coughing less severe, a little benzoin or pow- 
dered opium was added to the sulphur. These inhalations were practised 
morning and evening, the patient fasting and afterward exercising in the 
open air. Appropriate medication, according to the symptoms, completed 
the treatment. Seventy patients, at difl'erent stages of tuberculosis, were 
subjected by M. xluriol to the inhalation of the sulphur vapor. Their sputa, 
previously examined, contained bacilli, and, inoculated in the guinea-pig, 
caused phthisis in a short time. Thirty of these patients, who were in incip- 
ient tuberculosis, obtained an arrest of the progress of the disease, disappear- 
ance of the fever and sweats, return of the appetite, and increase in weight. 
The bacilli disappeared from the sputum. M. Auriol believes that these 
cases are cured, since the improvement has continued more than two years. 
The tubercles, he thinks, are transformed into fibrous tissue. Twenty others 
of the seventy tubercular cases did not have this treatment long enough to 
determine its value, or received it in an irregular manner. Nevertheless, they 
stated that they derived benefit from it. The remaining 20 had general tuber- 
culosis and succumbed to the disease. M. Auriol employed sulphurous acid 
in the treatment of guinea-pigs that were rendered tuberculous by inocula- 
tion. They improved in flesh and weight, and in those that were killed a 
considerable time afterward the tubercular nodules were found to be trans- 
formed wholly or chiefly into fibrous tissue. 

M. Dujardin-Beaumetz has constructed a very ingenious and simple lamp 
for producing sulphurous acid by burning the bisulphide of carbon. This 
produces 111.3 volumes of carbonic acid and 141.4 volumes of sulphurous 
acid. The carbonic acid does not seem to produce any injurious effect, but, 
on the other hand, its anaesthetic action increases the tolerance and diminishes 
the irritation of the sulphurous acid. The Bulletin general de Therapeutique., 
February 29, 1888, contains a full description of Dujardin-Beaumetz's appar- 
atus which is too lengthy for insertion here. 



ETIOLOGY. 251 

I have described in the foregoing pages the most important of the remedies 
which have been recently recommended by apparently competant observers. 
There are others which, from their nature and the limited trial which they 
have received, I have not thought of sufficient importance to require notice. 
Most of them will probably soon be discarded by those who now recommend 
them. The hygienic measures — as outdoor life, residence at a high altitude, 
free ventilation of sleeping apartment, and the use of the most nutritious and 
easily-digested food — still maintain a most important place in the treatment 
of tuberculosis. Of the medicines, creasote used internally and by inha- 
lation, the inhalation of sulphurous acid vapor, not carried to the extent of 
irritating the air-passages, and the use of germicide sprays, as of corrosive 
sublimate, the terebinthinate vapors, etc., appear to be the most deserving of 
recommendation. But no doubt the next ten years will witness important 
changes in the treatme-nt of tuberculosis based on its microbic nature, and 
probably remedies not now heard of will come into use. 



CHAPTER lY. 

SYPHILIS. 

Syphilis in infancy and childhood occurs under two forms — to wit, the 
congenital and acquired. The former is the more frequent. 

Etiology. — Congenital syphilis may be derived from cither father or 
mother. Either parent, having syphilis in its first or second stage, may 
transmit it to the offspring, although at the time free from syphilitic symp- 
toms. The mother, healthy at the time of conception and contracting 
syphilis prior to the eighth month of gestation, may communicate the dis- 
ease to the fcetus. Syphilis contracted by the mother in the eighth or ninth 
month of gestation is less likely to be communicated to the foetus. Writers 
mention the case reported by Zeissel, in which the wife, previously well, con- 
tracted syphilis from her husband between the fifth and seventh months of ges- 
tation, and the infant, born at term, soon exhibited the characteristic syphilitic 
lesions. If both parents have syphilis at the time of conception, the infant 
is almost necessarily syphilitic; on the other hand, if only one parent be 
syphilitic, the infant may or may not be contaminated. Sometimes with such 
parentage a part of the children are syphilitic and a part healthy. 

All syphilographers agree that syphilis in its third stage is not transmis- 
sible from parent to child, but parents in this stage of the disease are likely 
to beget scrofulous children. Hutchinson of London regards syphilis as an 
exanthem, with its periods of efflorescence and decline, and the symptoms 
and ailments which characterize the so-called third stage he regards as 
sequelse. That syphilis is no longer transmissible after the close of the 
second stage is shown by many observations. Thus, M. Mireur relates the 
history of a man and wife who were syphilitic and were never treated, but 
their children were without syphilitic symptoms. 

Acquired syphilis in infancy and childhood may be received through 
primary lesions — that is, by reception of the virus from a chancre or bubo — 
or it may be derived from certain of the secondary lesions. Inoculation by 
primary lesions may occur at the birth of the infant from a syphilitic sore in 
the vagina or upon the vulva of the mother ; inoculation in this manner is, 
however, rare. Children may also receive the virus from primary lesions on 



252 SYPHILIS. 

the persons of nurses or companions. Infection in this manner is sometimes 
accidental and sometimes the result of criminal conduct. A chancre on the 
breast of the wet-nurse not very infrequently communicates syphilis to the 
nursling. 

The contagiousness of '^ secondary manifestations," for a long time doubted, 
is now fully established. Syphilis may be communicated by the secretion or 
exudation of a mucous patch or a secondary sore'. Hence the danger of 
suckling by infected wet-nurses, though they present no symptoms of recent 
syphilis. Excoriations or sores upon the nipple or breast of a syphilitic 
wet-nurse may communicate the disease to the nursling ; and, on the other 
hand, mucous tubercles or fissures upon the lips or tongue of the infected 
infant may be the means of contaminating a healthy wet-nurse. Many such 
cases are now contained in the records of medicine. Vaccination by means 
of the scab is also a mode by which syphilis has been communicated. (For 
further particulars in reference to this subject the reader is referred to our 
remarks on vaccination.) 

Syphilis is believed to be a microbic disease, but further investigations 
are required in order to determine positively which microbe is the causal 
agent. Klebs obtained by cultivation bacilli from rods and spherules which 
he found in indurated chancres. With these bacilli he produced a local 
affection by inoculation in the monkey which resembled, in some respects, 
that of syphilis and in other respects that of tuberculosis. Ziegler and Von 
Rinecker obtained negative results from similar experiments (Ziegler's Path. 
Anatomy). Lustgarten has described a bacillus which occurs in syphilitic 
lesions, and which he distinguishes from that of tuberculosis by colorations 
which the latter receives and this does not. Alvarez and Tavel in 1885, 
and later Cornil, describe a bacillus found in the desquamation of the genitals 
which closely resembles Lustgarten's bacillus of syphilis, but which Cornil 
states can be distinguished from it by certain differences in the coloration 
(^Cyclop, of Diseases of Children^ vol. i. 168, Phila., 1889). 

Dr. W. H. Welch, the distinguished professor of pathology in Johns Hop- 
kins University, has favored me with the following note relating to the micro- 
organism which causes syphilis : 

Baltimore, Aug. 14, 1889. 

There has hitherto been no satisfactory demonstration of this organism, 
although there have been many claims to its discovery. The only organism yet 
demonstrated which has any claims to being considered the cause of this disease 

is, in my opinion, the bacillus of Lustgarten There is much to be said in 

favor of the bacillus discovered by Lustgarten, and first described by him in 
November, 1884, and I think this is the only micro-organism hitherto observed 
in syphilitic lesions which possesses much interest. His work from the first 
attracted attention, as it was done under the direction of Prof. Weigert, one of 
the greatest living experts in this line of study. The organism is described by 
Lustgarten as a bacillus three to seven micro-millimetres long, often slightly wavy 
in shape, and found usually within the protoplasm Qf cells in syphilitic products. 
It was found by Lustgarten in all of the syphilitic products, including gummata, 
which he examined. Next to Lustgarten's, the most important studies of this 
bacillus have been made probably by Doutrelepont of Bonn, in co-operation with 
Schiitz ; by Matterstock of Wlirzburg; by Markase; and by Fordyce. The 
significance of Lustgarten's discovery for a time seemed to be overthrown by the 
detection by Matterstock and by Alvarez and Tavel of a bacillus in smegma, 
which these observers believed to be identical with Lustgarten's syphilitic bacillus ; 
but, although strikingly similar, these two species of organism have now, I 
believe, been shown to be entirely different species, and the smegma bacillus has 
nothing to do with the syphilis bacillus. 

Lustgarten's bacillus has not been cultivated, notwithstanding repeated 
attempts to find a medium suitable for its growth. It is certainly often, and prob- 



CLINICAL HISTORY. 253 

ably constantly, present in syphilitic lesions. Still, several observers have 
reported negative results in searching for it. The reason of this is probably the 
extraordinary difficulty in demonstrating this organism. There is nothing in all 
histological technique which requires such an outlay of time and patience as the 
demonstration of the syphilis bacillus, so that so skilled an histologist as 
Weigert says that he simply has not the patience to work at this subject ; and 
this is probably the conclusion of others who have tackled it. 

It is clear, however, that the discovery of a peculiar bacillus with remarkable 
staining properties, enclosed within cells in syphilitic products, is something of 
great significance — far greater than finding, as did Aufrect, ordinary cocci in 
juice squeezed out of a flat condyloma, or in mistaking plasma-cells for clumps 
of cocci, as Birch-Hirschfeld is known to have done. When, in addition to this, 
the few good observers who, like Lustgarten, have had the patience and skill to 
make a satisfactory study of the question, claim to find this peculiar bacillus so 
frequently in the lesions of syphilis, I think it must be admitted that this bacillus 
has special claims upon our consideration. It must be admitted, however, that 
a complete demonstration that Lustgarten's bacillus is the specific cause of 
syphilis has not as yet been furnished. 

It may interest you to know that within the last year or two some interest has 
attached to the observation first made by Kassowitz and Hochsinger, that strepto- 
cocci are often present in congenital syphilis; but I do not think that there can 
be any doubt that these streptococci have nothing to do with the specific con- 
tagium of syphilis (and, indeed, Doutrelepont has found Lustgarten's bacillus in 
combination with streptococci in congenital syphilis), but they are evidence of 
mixed infection. They are probably the ordinary streptococci of suppuration. It 
is, however, of some interest to have this bacteriological evidence of a clinical fact 
that many cases of congenital syphilis are examples of mixed infection. It is 
probable that some lesions of congenital syphilis which have been regarded as 
specific, particularly those of a suppurative character, are due to the secondary 
invasion of these streptococci, for Avhich the soil has been prepared by the specific 
organism of syphilis. Yours verv truly, 

W. H. Welch. 

It is evident, in consequence of the risk of begetting syphilitic children, 
that one who has contracted syphilis should not marry or sustain conjugal 
relations until four years have elapsed from the time of infection and the 
disease has passed through its first and second stages, and eighteen months 
of treatment have been employed. We have seen that hereditary syphilis 
may be inherited from either parent, although the parent do not exhibit at 
the time any sj'philitic symptoms, and that the mother, contracting syphilis 
during gestation even as late as the seventh month, may transmit it to her 
infant. 

Clinical History. — The effects of the syphilitic poison upon the devel- 
opment of the foetus and the development and health of the infant are differ- 
ent in difi"erent cases. The foetus, under the influence of the poison, often 
ceases to grow, shrivels, dies, and is expelled long before term ; or it may be 
born alive, but prematurely, and showing clear evidences of the disease as 
soon as it comes into the world ; or, again, it may be born at term, but dead. 
So frequently is syphilis a cause of non-viability that, as Trousseau has 
remarked, this disease should be suspected as the cause whenever a woman 
repeatedly aborts. Abortion from syphilis commonly occurs at or about the 
sixth month of gestation. In those cases in which the foetus dies from syph- 
ilis there is often placental syphilitic disease — to wit, an undue growth of 
cells in the villi, which, compressing the vessels, gives rise to fatty degenera- 
tion and prevents the requisite interchange between the maternal and foetal 
blood (Harring, Frankell). Frankell designated the change " granulation-cell 
hypertrophy of the placental villi." Virchow in one case found a gummy 
tumor in the maternal portion of the placenta. 

When a foetus destroyed by syphilis is expelled, it frequently presents a 



254 SYPHILIS. 

macerated appearance, the cuticle being detached over large patches of sur- 
face, and in other parts raised in blebs, with a thin, puriform, and offensive 
fluid underneath ; the liver is occasionally indurated, and abscesses with spots 
of inflammation are sometimes observed in the thymus gland ; the amniotic 
fluid is offensive, turbid, and of a greenish or greenish-brown appearance. 
If the foetus in which syphilitic manifestations have begun to occur have 
reached a viable age and be born alive, it is small and imperfectly developed, 
often shrivelled and senile in appearance. The skin looks unhealthy, and it 
may exhibit a distinct rash. Bouchut saw a seven and a half months' infant 
born alive, with an eruption of a copper color upon the legs and arms and 
onychia upon the fingers and toes. The bullas of pemphigus are also not infre- 
quent upon the skin at birth, or they appear within a few days (two or three) 
after birth. The smallest are about the size of a split pea, but many are 
considerably larger ; the largest consist of two or more which have coalesced. 
They contain a thin, greenish, purulent matter, and appear most frequently 
upon the palms of the hands and soles of the feet, but also in severe cases 
upon the face and over the surface of the body. Recently I was able to 
diagnosticate syphilis in an infant within a day after birth by its small size 
and feebleness and the appearance of large blebs of pemphigus upon its 
hands, feet, fingers, and toes, over which the skin soon broke, leaving trouble- 
some and bleeding sores ; coryza commenced about the twelfth day. The 
parents seemed healthy, but I was enabled to trace the syphilitic taint to the 
mother. Non-syphilitic pemphigus, the result of cachexia, sometimes appears 
soon after birth, but its primary and usual seat is around the neck and upon 
the body. I have known it to appear within the first week of life, and end 
fatally by the close of the second week. I have not found it difficult to dis- 
tinguish it from syphilitic pemphigus by the history of the family and its 
absence from the palmar and plantar surfaces of the hands and feet. Con- 
dylomata, mucous patches, and stains of a copper color are the principal 
syphilitic affections, besides pemphigus, which have been observed at birth 
on the bodies of contaminated infants. It is stated that M. Cullerier in ten 
years' attendance at the Hopital de Lorraine met only two cases of syphilitic 
manifestations at birth, and Victor de Meric only two cases in forty-six 
infants, who were affected with congenital syphilis (Bumstead) ; but in the 
practice of others a larger proportion have exhibited symptoms at birth. 
Ordinarily, the period in which congenital syphilis is first revealed by symp- 
toms is between the fifteenth and fortieth days. Rarely the manifestations 
of the disease are delayed several months. M. Diday ascertained the time of 
the commencement of symptoms in 158 cases, as follows : 

Before the completion of one month after birth, in 86 

Before the completion of two months after birth, in 45 

Before the completion of three months after birth, in 15 

At four months 7 

At five months . 1 

At six months 1 

At eight months 1 

At one year 1 

At two years 1 

When the symptoms do not occur until several weeks have elapsed, it is 
probable that the poison has been partially eradicated from the affected 
parents by appropriate treatment. 

The nutrition of the infant who has inherited the syphilitic taint, but 
does not exhibit it at birth, is for a time good, but it begins to be impaired 
when the local manifestations of syphilis appear or soon after. The system 



CLINICAL HISTORY. 255 

gradually wastes ; the skin loses its fresli and healthy appearance and becomes 
sallow, and after a time more or less wrinkled ; the features become pinched 
and contracted and wear a sad expression. M. Diday says : '• Next to this 
look of little old men, so common in new-born children doomed to syphilis, 
the most characteristic sign is the color of the skin."' Trousseau thus 
described this discoloration of the surface : '• Before the health becomes 
affected the child has already a peculiar appearance ; the skin, especially 
that of the face, loses its transparency ; it becomes dull, even when there 
is neither puffiness nor emaciation ; its rosy color disappears, and is replaced 
by a sooty tint, which resembles that of Asiatics. It is yellow or like coffee 
mixed w^ith milk, or looks as if it had been exposed to smoke ; it has an 
empyreumatic color, similar to that which exists on the fingers of persons 
who are in the habit of smoking cigarettes. It appears as if a layer of color- 
ing had been laid on unequally ; it sometimes occupies the whole of the skin, 
but is more marked in certain favorite spots, as the forehead, eyebrows, chin, 
nose, eyelids — in short, the most prominent parts of the face ; the deeper 
parts, such as the internal angle of the orbit, the hollow of the cheek, and 
that which separates the lower lip from the chin, almost always remain free 
from it. Although the face is commonly the part most affected, the rest of 
the body always participates more or less in this tint. The infant becomes 
pale and wan."" 

The infant whose system is profoundly affected by syphilis rarely smiles 
and its voice is feeble and plaintive ; its frequent, whimpering cry is quite 
characteristic. 

Coryza is one of the earliest and most constant of the local affections in 
infantile syphilis. It is slight at first, attracting little attention on the part 
of the parents, who are not aware of its significance and usually attribute it 
to a slight cold ; but it gradually increases. It gives rise to a secretion from 
the Schneiderian membrane, at first thin, but which becomes more consistent 
and is attended by the formation of scabs. The thickening of the mucous 
membrane in consequence of the inflammation and the presence of crusts nar- 
rows the passage through the nostrils, so as to produce snufiling respiration 
and sometimes render nursing difficult. In severe eases respiration through 
the nostrils is almost wholly prevented, so that death may occur from inanition, 
unless the breast be milked into the infant's mouth or it be fed with a spoon ; 
but ordinarily, even in grave coryza, it continues to nurse, though obliged 
often to release its hold of the nipple to obtain breath. It is when the coryza 
interferes with drawing the nipple that it first alarms the parents. The inflam- 
mation at the same time may affect the throat and larynx, causing hoarseness 
of the voice. Ulceration of the Schneiderian membrane and the adjacent carti- 
lage or bone is rare in infancy or childhood, although cases occur which are 
even attended with more or less flattening of the nose. Diday believes that 
the discharge which accompanies coryza is in great part due to mucous patches 
developed on the Schneiderian membrane. The upper lip, over which the dis- 
charge flows, becomes red. excoriated, and more or less incrusted. The coryza 
in most cases coexists with other local syphilitic affections. Occasionally it 
occurs alone, and is the only evidence of the presence of the specific taint, 
except such as is afforded by the malnutrition and general appearance of the 
patient. 

Mucous patches occur in most patients. They are developed either upon 
the mucous surfaces or upon parts of the skin which are thin and exposed to 
friction, and such as are moistened by secretion or transudation from the ves- 
sels underneath. The most common seat of mucous patches is at the termi- 
nation of mucous canals ; but in infancy, on account of the peculiar delicacy 
of the skin, they may occur upon almost any part of the cutaneous surface. 



256 SYPHILIS. 

They are most common, however, around the anus, upon the vulva, scrotum, 
umbilicus, labial commissures, in the axillae, and behind the ears. 

Mucous patches upon the skin present a rounded border and are slightly 
elevated. Their color has been compared to that of skin which has been soft- 
ened by the prolonged application of a poultice. Erosions and cracks some- 
times occur in the patches, from which a thin liquid exudes. 

Upon mucous surfaces they are less elevated than upon the skin, and are 
prone to ulcerate. These ulcerations, commencing at the centre, extend, and 
soon the mucous patch disappears and its site is occupied by an ulcer. The 
ulcer may be circular, oval, elliptical, crescentic, or irregular. The arches of 
the fauces are a common seat of mucous patches. 

Roseola is an occasional symptom of infantile syphilis.- " It is distin- 
guished," says Diday, '' by patches of a bright rose color, circumscribed, 
irregularly rounded, of various sizes (most frequently about as large as one 
of the nails) ; appearing by preference on the belly, lower part of the chest, 
neck, and inner surface of the extremities." The spots do not readily and 
fully disappear by pressure. 

Pemphiguii, appearing soon after birth, has already been alluded to. Its 
most frequent seat, whether occurring at birth or as a subsequent manifes- 
tation, is, as we have stated, the palms of the hands, soles of the feet, the 
fingers, and the toes. This eruption commences by a violet tint of the skin, 
and in the course of twenty-four to forty-eight hours a watery fluid collects 
underneath, which soon becomes turbid. The skin peels off", and sometimes 
an angry sore results, which bleeds readily when rubbed or pressed. In other 
and more favorable cases new skin takes the place of that which is lost. Pem- 
phigus at birth is a precursor of death, but when it appears for the first time 
some weeks after birth, it is a less unfavorable prognostic sign. In cases of 
recovery it disappears, with proper treatm'ent, in two or three weeks. 

Acne^ Impetigo.^ and Ecthyma are occasionally observed in children afflicted 
with syphilis. The indurated pustules of acne occur most frequently upon 
the shoulders, back, chest, and buttocks. The pus is sometimes absorbed and 
in other cases discharged, leaving a small cicatrix, which after a time disap- 
pears. Impetigo appears most frequently upon the face, and occasionally 
upon the chest, neck, axilla, and groin. Unlike simple impetigo, the syphilitic 
impetiginous eruption is surrounded by a copper-colored areola. Ecthyma 
occurs upon the legs and buttocks chiefly. It commences as violet-colored 
spots, which are soon transformed into pustules. Ulcers succeed, which in 
reduced states of the system sometimes enlarge and endanger the safety of 
the child. Of the three pustular eruptions, acne, according to Diday, is the 
least serious, indicating a " less confirmed diathesis." Ecthyma is the most 
serious, on account of the reduced state of the system with which it is usually 
associated. Syphilitic papulae and squamae are rare in infants, but cases have 
been observed. Onychia occasionally occurs, though less frequently than in 
syphilis of the adult. 

In an interesting lecture on hereditary syphilis Dr. Miller remarks that 
polymorphism of its cutaneous eruptions characterizes hereditary syphilis. 
In 1000 cases of the inherited disease the local affections referable to syphilis, 
and seated upon or in immediate relation with the cutaneous and mucous sur- 
faces, were as follows : ^ 

Papules 74 per cent, of the cases. 

Ehagades of the lips and anus 70 " " " " 

Khinitis 58 '' " '' " 

Ulcers of hard palate 52 " " " " 

Erythematous eruptions 45 " '' " " 

^ Pacific Med. Surg. Jour., 1888. 



VISCERAL LESIONS. 257 

Lymphadenitis chronica 20 per cent, of the cases. 

Ulcers of tongue (glossitis ulcerosa) 27 " " " 

Bullous eruptions (pemphigus) . 25 "' " " " 

Onychia and paronychia 23 " " " " 

Laryngitis .../.... 17 " " 

Pseudo-paralysis of extremities 7 '' " " " 

Ulcers ..'... 4 " " 

Ulcerative gingivitis 4 " " " 

Visceral Lesions. — The visceral lesions which result from the syphilis 
of infancy and childhood are suppuration in the thymus gland ; gummy 
tumors in certain organs, most frequently the lungs and liver; increase of 
the connective tissue of the liver, known as syphilitic cirrhosis ; partial peri- 
hepatitis, with depressions resembling cicatrices on the surface of the liver ; 
periostitis, with thickening of the bone : and exostosis. 

Suppurative inflammation in the thymus gland is not common or has not 
been frequently observed. When it is present the gland sometimes presents 
its normal appearance externally, and the abscess is only discovered by incis- 
ions. Gummy tumors are white and spheroidal ; some are as small or smaller 
than a pin's head, while others are as large as a pea or even a liazel-nut. I 
have seen a considerable number of them not as large as a pin's head in the 
liver of an infant. Gummy tumors, according to Lebert, consist " of loose 
fibrous tissue made up of pale, elastic fibres, enclosing in their large inter- 
spaces a homogeneous granular substance, the elements of which are less adhe- 
rent to each other than in deposits of true tubercle." Lebert also, with other 
microscopists, discovered round granular cells in these tumors. According to 
Robin, gummy tumors " are made up of rounded nuclei belonging to fibro- 
plastic cells, or cytohJastions ; of a finely granular, semi-transparent, and amor- 
phous substance ; and, finally, of isolated fibres of cellular tissue, a small 
number of elastic fibres, and a few capillary blood-vessels." 

Constitutional syphilis is one of the principal causes of waxy degenera- 
tion, and the spleen and liver of infants may be enlarged from this cause. 
Dr. Samuel Gee has expressed the opinion that in half the cases of hereditary 
syphilis the spleen is enlarged (^London Lancet., April 13, 1867). 

Infiltration of the liver by fibrous substance was first noticed by Gtibler. 
It is not common in the infant. A specimen, showing this lesion, was pre- 
sented to the London Pathological Society^ in 1866 by Dr. Samuel Wilks. 
The following remarks by Dr. Wilks convey a good idea of the appearance 
and state of the liver in syphilitic cirrhosis : '■ Having dissected the bodies 
of several infants who have died of congenital syphilis, I have found fatty 
livers and an inflammation of the capsule, but in only two have I discovered 
adventitious products of a fibrous character. The present example, however, 
corresponds in every particular with the disease described by Gtibler. It 
must be distinguished (at least as far as the naked-eye appearance reaches) 
from s^'philitic disease of adults, of which many specimens have been before 
the society. In these the organ is cicatrized on the surface and contains dis- 
tinct nodules of fibrous tissue ; while in the disease of children, as in the 
present specimen, the whole organ is infiltrated by a new material, and it 
consequently becomes, as described by Gtibler, hypertrophied, globular, and 
hard, resistant to pressure, and even when torn by the fingers its surface 
receives no indentation from them ; it is also elastic, and when cut creaks 
slightly under the scalpel. This was the form of disease in the present 
specimen. It came from a syphilitic child a month old, in whom the liver 
could be felt enlarged during life, and when removed weighed a pound and a 
half. It was smooth on the surface, and so hard that it resembled rather a 
fibrous tumor than a liver. It is seen that the liver in the syphilitic child is 
17 



258 SYPHILIS. 

liable to three distinct pathological processes — namely, gummy tumors, cir- 
rhosis or fibroid degeneration, and waxy degeneration." 

Syphilitic perihepatitis and periostitis are more rare in infancy and child- 
hood than in adult life, but they occasionally occur. The late Sir James Y. 
Simpson considered peritonitis in the foetus one of the results of syphilis, and 
a cause of its death. ^ 

Osseous Lesions. — Within the last few years important discoveries have 
been made in regard to the effect of syphilis upon the nutrition of the bones 
in children. In 1870, Dr. Wegner of Berlin published his observations of the 
state of the skeleton in twelve syphilitic children who were either stillborn 
or who died within a few days or weeks after birth. He found clear proof 
that the syphilitic dyscrasia frequently disturbs the nutrition and produces 
anatomical changes in the skeleton of the foetus. The following are the 
lesions clearly referable to syphilis which he observed : Periostitis of long 
bones, including the ribs ; softening, separation, and sometimes crepitation at 
the point of union of diaphysis and epiphysis ; chalky concretions and infil- 
trations along the line of ossification ; fatty degeneration of marrow ; irreg- 
ular formation and distribution of spongy substance in the epiphysis. These 
lesions were not all observed in each case, but they occurred with such fre- 
quency that there could be no doubt that they were due to the syphilitic taint 
of system. Confirmatory observations also in twelve cases have since been 
made by Waldeyer and Kobner.^ 

Again, there is a syphilitic lesion of the bone in children which is not 
usually present or has not usually been observed at birth, but is developed 
in the first weeks or months of infancy. The lesion alluded to is a circum- 
scribed enlargement of one or more bones. This has been most frequently 
observed upon the long bones, including the clavicle and ribs, but in certain 




children it occurs upon other bones in addition. In some cases it is one of 
the first manifestations of hereditary syphilis, occurring even sooner than the 

^ See elaborate paper by R. W. Taylor, M. D., New York Journal of Obstetrics, etc., 
July, 1874. 



PBOGNOSIS. 259 

coryza, while in others several months elapse before it appears. In one case 
reported by Dr. Bulkley^ of this city it was first seen only a few days after 
birth, being perhaps congenital ; while in another case, in which the enlarge- 
ment was upon certain phalanges, and which is represented in the accompany- 
ing figure, it appeared at the age of twelve months. When it occurs upon a 
phalangeal bone it is designated dactylitis syphilitica. 

The enlargement, if upon a long bone, ordinarily begins at or near the 
point of union of the diaphysis with the epiphysis. It is located upon the 
extremity of the shaft which it encircles, and it extends over a part or nearly 
the whole of the epiphysis. It has an elevation of perhaps one-half or three- 
quarters of an inch in typical cases : its surface is smooth or slightly undu- 
lating, and the skin over it, though distended, has its normal appearance and 
is easily movable, unless ulcerations have occurred. 

These enlargements, which result from the specific inflammation occurring 
in the periosteum and the bone, may resolve under proper treatment ; but if 
neglected and the antihygienic conditions are bad, degenerative changes may 
occur, ending in ulceration and destruction of the diseased part to a greater 
or less extent. 

Though these bone-enlargements, whenever observed, should excite 
suspicions of syphilis as the cause, enlargements which present the same 
general appearance do occur from other causes. Such a case was observed 
by me in the children's class in the Out-door Department of Bellvue, and Dr. 
Bulkley details another case in his paper. In the case observed by me the 
inflammation and enlargement seemed to be strumous. Baumler says : 
" Dactylitis syphilitica does not always originate in the bone ; similar appear- 
ances may be produced through gummous formation in the sheaths of the 
tendons and in the fibrous structure of the finger ;" and again, " Its outward 
appearance may be produced also by tuberculosis, enchondroma, or sarcoma 
of the bone-marrow" (art. "Syphilis," Ziemssens Encycl.). 

Mr. J. Hutchinson of London has called attention to the fact that hered- 
itary syphilis, having perhaps been manifested by the usual symptoms during 
infancy and then becoming latent, may give 
rise to new symptoms after the fourth year. 
The most noticeable of these symptoms is a 
dwarfing of the permanent incisor teeth, which 
are rounded and peg-like and their enamel 
notched at the free ends of the teeth. On 
account of the small size and shape of the 
teeth there are interspaces between them. 
This abnormal development is most marked 
in the central incisors of the upper jaw, and in certain cases it is limited to 
them, and it never appears in the other incisors unless it does also in them. 
Another symptom, which only appears in hereditary syphilis, is an interstitial 
keratitis occurring on both sides and attended by the deposition of fibrin in 
the substance of the cornea. In a few weeks the inflammation declines, but 
a slight opacity of the cornea remains. The cerebral nerves may become 
afFected,^ usually a single pair — if the auditory, deafness resulting ; if the 
optic, dimness of sight. Occasionally there are other manifestations of 
syphilis in this period, as enlargement of spleen and liver and nodes upon 
the long bones. 

Prognosis. — This depends in great part on the general condition of the 
patient. If there be much emaciation and the symptoms indicate a deeply- 
seated cachexia, a considerable proportion of the patients perish. On the 
other hand, if the general health be not greatly impaired, although the local 

' "Kare Cases of Congenital Syphilis," New York Med. Journal, May, 1874. 




260 SYPHILIS. 

affections are pretty severe, the prognosis with correct treatment is good. The 
younger the infant when the symptoms of syphilis appear, the more unfav- 
orable, as a rule, is the prognosis. 

Treatment. — Parents who beget syphilitic children ought, from a due 
regard for their offspring, to make use of antisyphilitic remedies, although 
they present in their persons no evidences of syphilitic taint. A good pre- 
scription for the parents is one-sixtieth of a grain of corrosive sublimate in 
the compound tincture of bark, given twice or three times daily for several 
months. If the father have had syphilis, both parents should be subjected to 
this treatment, and it may be continued, at least on the part of the mother, 
during the first months of her gestation. So small a dose of the mercurial 
does not, in my opinion, materially increase the liability to miscarry. There 
is much more danger of miscarrying from allowing the syphilitic taint to 
remain uncontrolled. Some prefer the use of mercurial ointment in the 
treatment of pregnant women having syphilis, in the belief that it is less likely 
to produce abortion. It is used for this purpose in the proportion of one 
drachm to the ounce. It is equally effectual in the eradication of the syph- 
ilitic taint with the small dose of corrosive sublimate recommended above for 
internal administration ; but it is impossible to determine the quantity of 
mercury which enters the circulation when inunction is employed and saliva- 
tion is more likely to occur. The following is, however, probably the best 
prescription for the treatment of parents infected by the syphilitic virus It 
should be given several months : 

R. Hydrarg. biniodidi, gi'- j ; 

Liq. potassii arsenit., 3iJ '■> 

Tine, belladonnae, gij ; 

Potassii iodidi, Jss; 

Aquse, q. s. ad ^iv. M. 

Dose : One teaspoonful three times daily after the meals. 

Or 

R. Vini, gvj; 

Pepsini puri in lamellis, ^ij ; 

Potassii iodidi, 3ij ; 

Liq. potassii arsenit., 3;ij ; 

Hydrarg. biniodidi, gr. j ; 

Qui. et ferri citratis, ^ij 5 

Syr. simplic, ^ij ; 

01. anisi, gtt. iij. Misce. 
Dose: One dessertspoonful three times daily. 

The nutrition of the infant that has unfortunately inherited the syphilitic 
taint requires special attention. Besides exhibiting the characteristic symp- 
toms of the disease, it usually suffers from innutrition, and sometimes passes 
into a state of decided marasmus. The mother who has given birth to a 
syphilitic infant should, if possible, wet-nurse it. Even if she never has 
exhibited any symptoms of the disease in her own person, she cannot contract 
syphilis from her infant. Colles wrote as follows in 1837 : " One fact well 
deserving our attention is this : that a child born of a mother who is with- 
out obvious venereal symptoms, and which, without being exposed to any 
infection subsequent to its birth, shows this disease when a few weeks old, — 
this child will infect the most healthy nurse, whether she suckle it or merely 
handle and dress it; and yet this child is never known to infect its own 
mother, even though she suckle it while it has venereal ulcers of the lips and 
tongue." This remarkable law relating to the immunity of mothers has been 
fully accepted by all subsequent syphilographers. On the other hand, a wet- 



TREATMENT. 261 

nurse employed to suckle a syphilitic infant is very liable to contract the dis- 
ease, through her nipples, from the infected lips of the infant. If a wet-nurse 
be employed for such an infant, she should be aware of the risk she incurs, 
and should protect herself by the use of an artificial nipple. At the same 
time, the infant should be placed fully under antisyphilitic treatment. Artificial 
feeding, though usually disastrous, is preferable to the propagation of the dis- 
ease to a healthy wet-nurse. 

Syphilis in the infant requires mercurial treatment as in the adult. Mer- 
cury may be employed internally or by inunction. Some prefer inunction in 
the treatment of ordinary cases in the manner recommended by Sir Benjamin 
Brodie. " I have spread," says he, " mercurial ointment, made in the propor- 
tion of a drachm to an ounce, over a flannel roller, and bound it round the 
child once a day. The child kicks about, and, the cuticle being thin, the 
mercury is absorbed. It does not either gripe or purge, nor does it make the 
gums sore, but it cures the disease. I have adopted this practice in a great 
many cases with the most signal success." The oleate of mercury, 10 per 
cent., is a better preparation for inunction. Five drops may be. rubbed in 
three times daily. Trousseau, on the other hand, discountenances the use 
of inunction, since mercurial ointment applied to the skin produces irritation 
and increases the suff'ering and restlessness of the child. He prefers the fol- 
lowing solution, which is known as Van Swieten's, for internal treatment: 

• R. Hydrarg. bichlorid., Ipart; 

A quae, 950 parts ; 

Spts. rectific, 100 parts. Misce. 

Dose : One or at most two grammes (15.434 to 30.868 grains), in milk, daily. 

In order to avoid the risk of establishing a diarrhoea, and to leave the 
stomach free for the employment of other medicines, as cod-liver oil and the 
iodide of iron, I prefer and commonly prescribe for infants inunction with the 
mercurial ointment diluted with eight times its quantity of lard, cold cream, 
or vaseline. It should not be applied as a plaster, but a quantity of the size 
of a large chestnut should be rubbed three times daily upon the neck or breast 
of an infant of three or four months. For children over the age of eight or ten 
months. Van Swieten's or one of the following formulae may be employed : 



ijc. Jdydrarg. cum. creta, 
Sach. alb., 
Divid. in chart. No. xii. One powder three times 


daily. 


9j. Misce. 


R. Hydrarg. clilor. corros., 
Syr. sarsDe com p., 
Aquse, 
Dose : One teaspoonful three times daily. 




gr. ss-j ; 

.^ij j . 

Jviij. Misce. 


B. Hyd. chlor. corros., gr. ss; 
' Potas. iodld., 5j ; 
Ferri et am men. citrat., .^j ; 
Syr. simplic, '|vj. Misce. 
Dose : One teaspoonful three times daily for a child of three to five years. 


R. Hyd. chlor. corros., 
Potas. iodid., 




gr- j ; 

3y; 



Syrup, simplic, 
Aquse, da. ^ij. Misce. 

Dose : Six drops three times daily for a child of three months. 

Prof. A. Jacobi recommends, in the treatment of syphilis of the newly- 



262 SYPHILIS. 

born, one-twentieth of a grain of calomel, to be given three times daily. An 
important advantage of its use is the rapidity and certainty of its action. 

Mercury, in whatever way employed, should not be discontinued entirely 
till several weeks after the syphilitic symptoms have disappeared ; it is proper 
to continue it for a time, in diminished quantity and fewer doses, after the 
health seems fully restored. 

When the mercurial is omitted tonics are often required. The prepa- 
rations of cinchona are useful in certain cases, as are also those of iron. If 
the patient remain feeble and pallid, presenting evidences of struma, cod-liver 
oil and syrup of the iodide of iron will be found beneficial, continued for some 
weeks or months after the mercury is discontinued. Attention should always 
be given to cleanliness and the hygienic management of the patient. In some 
instances direct treatment of the local affections is serviceable. To aid in the 
cure of syphilitic coryza the following ointment should be applied within the 
nostrils by a nasal sponge three times daily : 

R. Ung. hydrarg. nitratis, ^ij ; 

Ung. zinci oxidi, ^ij. Misce. 

Recently I have been in the habit of employing Squibb' s oleate of mer- 
cury, 2 per cent., for syphilitic coryza of infants, and the effect has been 
satisfactory. It may also be employed by cutaneous inunction in the treat- 
ment of the general disease. 

Condylomata or mucous patches seated upon the cutaneous surface should 
be dusted with calomel. At my clinique in April, 1871, a child two years 
and ten months old was presented, with a large condylomatous outgrowth 
near the anus. The history of the child showed that in all probability the 
disease had been contracted within a year from syphilitic children in one of 
the public institutions. Within three weeks this affection disappeared by 
dusting upon it calomel once daily, with appropriate internal treatment. 

The infant should be kept clean by bathing it in tepid water twice daily, 
and excoriations upon its lips or mucous patches should be bathed before the 
nursing with some mild disinfectant solution, as boracic acid. The best pos- 
sible hygienic conditions should be provided for the infant, since cachexia 
is commonly present. It should be taken outdoor frequently in suitable 
weather, and its removal from the city to the country, especially in hot 
weather, may be advisable. The cachexia which remains after the disap- 
pearance of the syphilitic manifestations requires the use of tonics, as cod- 
liver oil and syrup of the iodide of iron. 

Syphilitic symptoms may reappear during childhood. The exanthemata 
rarely appear at this age when the proper treatment has been employed in 
infancy, but condylomata and gummy tumors may, and they require a return 
to the mercurial treatment. If the bones are affected the iodide of potassium 
is the proper remedy. It causes the disappearance of the periosteal pains 
and swelling, and manifest improvement in the symptoms generally. 



SECTIOlSr II. 

ERUPTIVE FEVERS, 



CHAPTEK I. 

MEASLES. 

The disease known in the vernacular as measles has also the names 
rubeola and morbilli. It is a common exanthematic aifection occurring at 
any age, but most frequently in childhood. It affects once the majority of 
mankind. AYriters recognize three stages of measles : first, that of invasion, 
which ends with the appearance of the eruption ; secondly, the eruptive 
stage ; and, thirdly, the stage of decline or desquamation. 

Etiology. — Micrococci have been found in the blood of rubeolar patients 
by Coze and Feltz. Keating also discovered them during an epidemic of 
malignant measles {Phila. Med. Times, Aug. 12, 1882), and Ransome, Braid- 
wood, and Vacher found them in the breath of patients as well as in their 
tissues (Brit. Med. Jour., Jan. 21, 1882). It seems probable that they are 
the specific principle ; if so, they remain dormant in the system about twelve 
days, which is the incubative period. Additional observations are required 
in order to determine positively whether this micrococcus be the causal agent 
in measles, or whether it may not be some other microbe. 

Symptoms. — This disease commences with such symptoms as usually 
occur in mild but pretty general inflammation of the air-passages — to wit, 
cough, fever, anorexia, and thirst. The eyes present a suffused, moderately 
injected, and brilliant appearance, and the buccal and faucial surfaces are 
injected. The Schneiderian membrane and that lining the larynx, trachea, 
and bronchial tubes participate in the increased vascularity. The cough at 
first is dry, and sometimes distinctly croupy. Catarrhal or false croup, 
indeed, is not infrequent in the initial period of measles. The cough is 
attended with slight acceleration of respiration and by little or no pain in 
the respiratory movements. If auscultation be practised at this early stage, 
we observe the vesicular murmur, somewhat harsh in character, and some- 
times sonorous and sibilant rales. A little later rales of a moist character 
appear. 

The patient, if old enough, commonly complains of headache and of dull 
pain in the epigastric region or the centre of the sternum, due to the bron- 
chitis. With these local symptoms febrile reaction occurs. The tempera- 
ture rises to about 102° or 103°, as indicated by the thermometer in the 
axilla. The pulse numbers from 110 to 130 per minute. The febrile move- 
ment is greater than in primary tracheo-bronchitis, except when the bron- 

263 



264 MEASLES. 

chitis extends to the bronchioles, but it is less than in most cases of scarlet 
fever. 

The fever in the premonitory stage of measles after the first day is not 
uniform. It is attended by remissions and exacerbations, the former occur- 
ring in the first part of the day, the latter in the evening. Sometimes two 
exacerbations occur in the day. The face is flushed and somewhat swollen, 
especially during the times of increase in the fever, and the child is drowsy 
or restless. Vomiting, so common a symptom in the commencement of scar- 
let fever, occasionally occurs in measles. While in scarlet fever this takes 
place in the first twenty-four hours, in measles it takes place with about 
equal frequency at any period previously to the eruption. It was present 
during the first stage, sometimes almost as late as the eruptive period, in 
13, and was absent in 23 cases in which I preserved records in reference 
to this symptom. 

The duration of the first stage varies in different cases. It is usually 
from two to five days, with an average of about four. Occasionally it is 
more protracted on account of some disturbance in the economy, either from 
exposure to cold or other cause, which prevents the necessary afflux of blood 
toward the surface and retards the eruption. In 18 cases in my practice 
in which the duration of the cough previously to the appearance of the rash 
was accurately ascertained, the time varied from one to five days, with an 
average of three and one-third; in 10 other cases it had continued, the 
parents stated, about a week; and in 5, from from one to two weeks pre- 
viously to the eruption. 

The eruption commences, when the disease pursues its normal course, 
upon the forehead and neck, then the face, and gradually extends downward, 
occupying from twenty-four to thirty-six hours in passing over the trunk 
and limbs. It appears first as indistinct red points, not more than a line in 
diameter, which increase in size and become more distinct. Their borders 
are uneven or irregular or they are finely notched ; their general shape is, 
however, circular, except as two or more unite, when they may assume any form. 
The crescentic form which writers describe is due to the union of two points 
of eruption. The largest of these spots, when there is no coalescence, do 
not exceed a quarter of an inch in diameter, and many are much smaller. 
Frequently in plethoric children, if there be much fever, there is continuous 
redness over several inches of surface. The eruption is then confluent. 
This form is often observed upon the parts of the surface where the capil- 
lary circulation is most active when it is discrete elsewhere. In. some of 
these cases diagnosis of measles from scarlet fever is attended with 
difiiculty. 

The rubeolous eruption is slightly elevated, the elevation not being 
appreciable to the sight, but it can be ascertained by passing the finger over 
the skin, when roughness is felt at the point of eruption. Som.etimes the 
elevation, especially in the commencement of the efflorescence, is not appre- 
ciable, even to the touch. The eruption is broad and flat, never acuminate, 
never changing its form to the vesicular or pustular. It disappears by pres- 
sure, and immediately reappears when the pressure is removed. It has been 
compared in appearance to flea-bites. Small, pointed, papular, vesicular, or 
pustular eruptions are sometimes seen in connection with those of measles, 
but they are accidental, occurring in other states of the system, as well as in 
measles, if there be the same augmented temperature. 

In the commencement of the eruptive period the severity of the consti- 
tutional and local symptoms increases. The pulse and temperature corre- 
spond with the character which they presented during the exacerbations of 
the first stage. The features are slightly swollen; the eyes still watery and' 



SYMPT03m 265 

sensitive to light; the conjunctiva, ocular and palpebral, and the mucous 
membrane of the cavity of the mouth and of the air-passages, continue 
injected. The tongue is covered with a moist thin fur, and its papillae are 
prominent, though less so than in scarlet fever. The cough continues fre- 
quent, and is seldom attended with much expectoration in uncomplicated 
cases ; often there is no expectoration whatever. The appetite is lost, but 
drinks are readily taken on account of the thirst. Diarrhoea sometimes 
occurs on the first day of the eruption, but it lasts only a few hours, and, 
if the disease pursue its usual course, abates of itself. With the exception 
of this the bowels are regular or a little constipated during the eruptive 
period. 

On the second day of the eruption, or sixth of the fever, the symptoms 
begin to abate. The pulse is less accelerated and the temperature dimin- 
ishes ; the cough is less frequent and is easier, and the flushed and swollen 
appearance of the face declines. By the close of the third or on the fourth 
day the rash has disappeared in the order in which it extended over the body. 
There only remain faint maculae, which in the course of a day or two fade 
completely. 

With the disappearance of the rash the fever nearly or quite ceases, but 
a slight and painless cough continues for several days. 

Occasionally the eruption presents a livid appearance ; this is the rubeola 
nigra of writers. From cases which I have observed it is my opinion that 
this should not be considered a distinct species in the vast majority of 
patients, but that the dark color is due to internal inflammation, usually 
capillary bronchitis or pneumonia, which prevents full decarbonization of the 
blood. Rarely, rubeola nigra is due to the vitiated state of the blood or the 
malignant nature of the disease. The course of the eruption in this form of 
measles is somewhat difi"erent ; it continues longer, fades more slowly, and 
does not disappear so readily on pressure. Traces of it are observed a week 
or more after its first appearance ; it is likely to be fatal. Measles may pre- 
sent this form from the beginning, or, commencing as vulgaris, it may pass 
into rubeola nigra. 

Measles may be irregular in form, but aberrations are less frequent than 
in scarlet fever. Writers describe measles without catarrh, and, on the other 
hand, with catarrh, but without the rash. But positive diagnosis in such 
cases must be difficult. It is probable that simple catarrh and roseola have 
sometimes been mistaken for the two forms of irregularity mentioned , but 
when a child in a family of children afl'ected with measles presents all the 
symptoms of that disease except the catarrh or except the eruption, the diag- 
nosis of irregular measles would, as a rule, be correct. 

Occasionally the stage of invasion is very short or even absent. In one 
case the parents informed me that the catarrhal symptoms began on the day 
when the eruption appeared. Convulsions sometimes occur at the commence- 
ment of measles, as well as during its progress. A single convulsive attack 
at the commencement is usually not dangerous ; when repeated it is more 
serious ; it is also more serious when it occurs in the course of measles. 
In certain patients the eruption appears in an irregular and partial manner, 
occurring perhaps at a late period, and indistinctly, upon the trunk alone 
or upon the trunk and partially upon the legs. In many cases of deferred 
or partial eruption there is internal congestion or inflammation of some part, 
which causes withdrawal of blood from the surface, and thus prevents the 
normal development of the rash. 

When the eruption disappears the third stage commences, that of des- 
quamation. It is characterized by a scanty furfuraceous exfoliation of the 
epidermis. The desquamation is seldom as great as in scarlet fever, and it 



266 ■ MEASLES. 

occurs most where the eruption has been thickest and the epidermis most 
inflamed. Exfoliation occurs between the fourth and seventh days after 
the commencement of the eruption, the eighth and the eleventh of the 
disease. Frequently it does not take place, or is so slight as not to be 
observed. 

With the disappearance of the rash the symptoms rapidly abate. The 
pulse becomes more natural, the temperature is reduced, the digestive organs 
return to their normal state, and convalescence is established. The cough 
continues several days after the other symptoms abate, but it is less and less 
frequent, and is not painful. 

Complications. — The complications of this disease are important. Much 
of the success of the physician in the management of measles depends upon 
a correct diagnosis and understanding of them. The most frequent of these 
complications are bronchitis and broncho-pneumonia. Slight bronchitis is 
uniformly present in measles, but if it increase so as to cause embarrassment 
of respiration and become a source of danger, it is properly a complication. 
This complication, as well as pneumonia, may occur at any period of measles, 
but it commences most frequently in the first stage. Occurring in the first 
stage, it may prevent the regular appearance of the rash ; if in the second 
stage, it often causes retrocession of it. 

When bronchitis becomes really serious it usually has invaded the minute 
bronchial tubes. This disease, designated capillary bronchitis or suffocative 
catarrh, I have elsewhere described. The clinical history of fatal bronchitis 
as a complication of measles is as follows : The respiration, at first not notably 
altered, becomes by degrees accelerated and the patient more and more fret- 
ful. The pulse, instead of becoming less accelerated, as after the first days 
of simple measles, is daily more rapid and the respiration more frequent and 
labored. The dyspnoea gradually increases, the inframammary region is 
depressed during each inspiration, and the subcrepitant rale is heard on both 
sides of the chest. There is probably collapse or inflammation of some of 
the lobules. Finally, the prolabia and fingers become livid, and death occurs 
from apnoea. Capillary bronchitis, occurring as a complication and continuing 
as a sequel of measles, usually becomes a broncho-pneumonia. A large pro- 
portion of those aff'ected under the age of three years die. The anatomical 
characters of fatal bronchitis occurring in connection with measles we have 
had frequent opportunities to inspect in the Foundling Asylum and Infant 
Asylum. In some cases there have been evidences of continuous inflamma- 
tion from the epiglottis downward, ending in lobular or broncho-pneumonia. 
Broncho-pneumonia as a complication does not diff"er materially from the 
idiopathic inflammation, except that it is more protracted and fatal. 

The next most frequent serious complication of measles is entero-colitis. 
This may commence at any period during the course of the disease. If the 
colon be more especially the seat of inflammation, the evacuations contain 
mucus and blood, unless in young children, in whom the stools, even in 
severe colitis, commonly have a green color. The anatomical character of 
this complication varies in difl"erent cases, like the idiopathic form of inflam- 
mation. Sometimes there is simple arborescence of the intestinal mucous 
membrane, with tumefaction of its follicles ; in other cases, in addition to 
increased vascularity, the mucous coat is softened and thickened ; and in 
others still, especially if the inflammatory action has been protracted, ulcer- 
ation occurs, for the most part in the site of the solitary glands. Excep- 
tionally, in fatal cases of measles attended with diarrhoea, no vascularity is 
observed after death, although the intestines may be thickened and softened. 
In such cases the diarrhoea was probably inflammatory, the injection of the 
vessels having disappeared after death. 



COMPLICATIOyS. 267 

Severe and obstinate diarrhoeal affections occurring with measles usually 
commence as the primary disease is about declining. They then become 
sequelae, ending fatally in many instances, especially in the summer months, 
several days or perhaps weeks after the disappearance of the eruption. 
Diarrhoeal attacks occurring in or previously to the eruptive stage are, as 
a rule, mild and easily relieved. 

In some grave cases measles have a tendency from the first to affect the 
internal organs more than the surface. Bronchitis, pneumonia, and entero- 
colitis may coexist with indistinctness of the eruption on the skin. Such 
complications render a fatal result highly probable. 

Eclampsia is also an occasional very dangerous complication. It some- 
times occurs very suddenly and unexpectedly. A child of five years, in my 
practice, apparently progressing favorably with measles, was allowed to sit at 
dinner with the family ; suddenly and without premonition eclampsia occurred, 
the rash receded, and notwithstanding vigorous treatment death resulted in 
a few hours. Rapidly-developed cerebral congestion seemed to be present. 
To prevent such a complication the patient should remain quiet in bed dur- 
ing the eruptive stage. 

Another very fatal complication and sequel is pseudo-membranous laryn- 
gitis, commencing when rubeola is beginning to decline ; but it is less frequent 
than pneumonia or entero-colitis. In catarrhal or false croup — which, as has 
been previously stated, is not infrequent at the commencement of measles — 
the cough has a loud, ringing character. In membranous laryngitis, on the 
other hand, it is hoarse or harsh and less distinct, on account of the presence 
of the pseudo-membrane in the larynx. This form of laryngitis, always a 
grave disease, is more serious when it occurs as a complication of measles than 
when it is idiopathic, not only because the blood is vitiated and the system 
reduced by the primary affection, but because the inflammation of the mucous 
surface is in general more extensive, as is also the pseudo-membrane. This 
membrane in the croup of measles often extends so far down the air-passages 
that neither intubation nor tracheotomy can produce any decided ameliora- 
tion of symptoms. This complication, though always grave, is not, however, 
necessarily fatal. I have known cases recover by inhalation of solvent sprays 
when for days there had been dyspnoea and other evidences of a pretty firm 
pseudo-membrane. True croup causes continuation of the fever, which had 
perhaps begun to abate. 

Diphtheria, when epidemic, also frequently complicates measles. Much 
of the mortality from measles in this city since the year 1858 was due to 
this cause. In cases observed by myself diphtheria usually began while the 
fauces were still inflamed, and sometimes before the eruption had begun to fade. 
The pseudo-membranous laryngitis or true croup mentioned above is, in most 
instances, in localities where diphtheria prevails, a local manifestation of 
this disease. 

These are the most common complications of measles. There are others 
of less frequent occurrence, among which may be mentioned stomatitis, pha- 
ryngitis, and otitis sufficiently severe to be considered complications. Earely, 
also, purpura, attended by hemorrhages from the different mucous surfaces, 
occurs in connection with measles. This complication is, however, more fre- 
quent in certain other constitutional diseases, as scarlet fever, and especially 
variola. 

It is seen that the inflammations which occur in the course of measles 
are chiefly of the mucous surfaces. In scarlet fever, on the other hand, the 
inflammations are more frequently of serous surfaces. 

There are other affections originating in measles which are rather sequelae 
than complications. Gangrene of the mouth is one which, as stated in another 



268 MEASLES. 

part of this book, occurs more frequently after measles than any other disease. 
After a severe epidemic of measles in the New York Foundling Asylum in 
1874 three cases of gangrenous vulvitis occurred in those who had been 
aifected. Ophthalmia commencing in measles often persists for weeks or 
months. It may give rise to granulation of the lids, and cases have been 
reported of violent inflammation of a purulent character producing ulcera- 
tion of the cornea and destroying vision. The ophthalmia is sometimes very 
intractable. Inflammation of the Schneiderian membrane, commonly present 
during measles, often continues as a sequel, extending back as far as the Eusta- 
chian tube, where it may cause swelling, with impairment of hearing, and 
forward to the lip, where it may produce chronic eczema. Prof. Moos has 
described the lesions which occur in the labyrinth in measles when the ear 
is aff'ected. Cells and coagulated lymph fill the semicircular canals and the 
cochlea, and collect in the lymphatics. The blood-vessels in the Haversian 
canals and in the spiral ligament are nearly destroyed. The nerves become 
gelatinous and atrophy; the muscular fibres undergo waxy degeneration. 
Notwithstanding such lesions, permanent deafness is rare and reparation 
seems possible (^Congress at Wiesbaden, Sept. 22, 188Y). 

Anatomical Characters. — I have made or witnessed, mainly in insti- 
tutions, a considerable number of post-mortem examinations of those who 
have died in or after an attack of measles. In all there were lesions due to 
complications. Indeed, death directly from measles is so rare that few have 
had an opportunity of studying the anatomical charcters apart from the com- 
plications. In those who have died without any obvious coexisting disease — 
and these cases chiefly occur in the malignant form — there has been congestion 
of the internal organs, especially marked in the lungs, and sometimes the tis- 
sues appeared softened. The blood also in the malignant form has a darker 
hue than natural, and ecchymotic patches have been observed upon the mucous 
surfaces and elsewhere, corresponding in character with the petechias under 
the skin which sometimes occur in this form of measles. In cases resulting 
fatally from bronchitis or pneumonia the bronchial glands are commonly tume- 
fied in the same manner as the mesenteric glands are enlarged in enteritis and 
the glands of the mesocolon in dysentery. 

Nature. — Rubeola, like the other exanthematic fevers, is due to a mate- 
ries morbi, probably micrococci, as has been stated above. It is highly con- 
tagious through the air. It has been inoculated by the serum from vesicles 
which sometimes occur in connection with the rubeolous eruption, and also 
by the blood from a patient. Inoculation does not appear to moderate the 
disease, and as measles, when contracted in the ordinary way, is not in itself 
dangerous, but dangerous only from complications, inoculation is not per- 
formed except as a matter of scientific interest. The usual mode of prop- 
agation is through the air. Measles is communicated by the breath and prob- 
ably by exhalations from the surface. Under whatever circumstances it occurs, 
the specific principle has been communicated from some infected person. We 
frequently meet cases, as one in a sparsely-settled district that has come to 
my knowledge, in which exposure cannot l3e traced. Yet the immunity of 
certain islands for centuries till infected through commerce renders the doc- 
trine of an origin de novo improbable. 

Twelve to fourteen days elapse from the time of infection to the com- 
mencement of the eruption. In cases observed in the children's department 
of Charity Hospital the incubative period was ascertained to be about twelve 
days. In those who have been inoculated the incubative period is said to have 
been about one week. Rubeola prevails epidemically, like the whole class of 
infectious diseases, and in difl'erent epidemics the type may vary as well as 
the character of the complications. 



TREATMENT. 269 

Diagnosis. — The diagnosis of measles previously to the eruption is often 
difficult. The catarrhal symptoms then predominate, and these are such as 
may occur independently of any constitutional or blood disease. The iBrst 
stage, therefore, is not infrequently mistaken for coryza or mild bronchitis. 
The points of differential diagnosis are the suifused appearance of the eyes, 
the greater degree of fever on the first day than would be likely to arise 
from so moderate an amount of local disease, and morning remission and 
evening exacerbation of the fever. Measles in the first stage has been mis- 
taken for remittent fever. The catarrhal symptoms should prevent such an 
error. 

Sometimes roseola closely resembles measles in appearance, but the rash 
of roseola appears within a few hours after the commencement of febrile 
symptoms, and almost simultaneously over the whole body, and without 
those local symptoms referable to the mucous surfaces which characterize 
measles. 

A^ariola on the first day of the eruption has sometimes been diagnosti- 
cated measles. I recollect once being called to an infant with fatal confluent 
smallpox who was said to have measles. A physician a few days previously, 
observing the red points in the commencement of the eruption, had made 
this absurd diagnosis, and, predicting a favorable result, had not thought it 
necessary to repeat his visit. In case of doubt it is the part of prudence to 
defer making a positive diagnosis. A few hours suffice to show the distinct- 
ive characters of rubeolous and variolous eruptions. But the anxiety of 
friends often necessitates the expression of opinion. The absence or light- 
ness of catarrhal symptoms, the earlier appearance of the eruption, and its 
papular feel under the finger in smallpox, enable us to discriminate between 
the two diseases in the commencement of the eruptive stage. Moreover, the 
symptoms in the initial periods are different, as will be seen in our description 
of smallpox. 

Prognosis. — This is favorable, provided that no serious complication 
arises. With internal inflammatory complication, on the other hand, the dis- 
ease becomes much more grave. A large proportion thus affected die. The 
prognosis is less favorable in feeble children with scanty eruption or an 
eruption appearing at a late period and irregularly. Dyspnoea, persistent and 
great acceleration of pulse, and coma indicate an unfavorable ending. Con- 
vulsions occur much more rarely in the course of measles than in scarlet 
fever, and when they occur after the initial period they usually end in coma 
and death. The mortality from measles varies greatly according to the 
severity of the type, but more according to the season, the locality, the sur- 
roundings, and the care which the patients receive, which determine the 
liability to complications. Thus in the cities the mortality is large from 
measles in the hot months among infants, who at this time are very liable to 
gastro-intestinal catarrh. It also seems to be larger in the asylums than in 
family practice. In epidemics in Boston and Pont de I'Arche the mortality 
was 5 per cent, of the cases, in Neufchatel, Switzerland, 2 per cent., and 
among the Sioux Indians, at Crow Creek Agency, Dakota, Q.QQ per cent. 
^Therapeutic Gaz., July 16, 1888). 

Treatment. — Uncomplicated rubeola requires little medicinal treatment 
except to palliate symptoms. The child should be kept in an airy apartment 
at a uniform temperature of about 70°. A temperature so elevated as to be 
uncomfortable to the nurse is injurious to the patient. But while the pop- 
ular idea is erroneous that he should be kept in a heated atmosphere, it is 
correct that currents of air and sudden reduction of temperature are dan- 
gerous. A violent and fatal attack of croup occurred in my practice in a 
girl of fifteen in consequence of exposure at an open window at the close of 



270 MEASLES. 

the eruptive stage. The diet should be mild, and for the most part liquid. 
The patient, indeed, refuses solid food, but on account of the thirst takes 
liquids more readily. Farinaceous substances, with milk, afford sufficient 
nutriment in ordinary cases. If the previous health have been poor and the 
vital powers reduced, or if there be a complication, more sustaining diet is 
required. Stimulation by wine or brandy is needed in these cases. During 
the two or three weeks succeeding an attack of measles care should be taken 
to avoid exposure to cold or changes of temperature, since during this period 
there is great liability to inflammations of the mucous surfaces. 

The cough ordinarily requires treatment, inasmuch as the suifering of 
the child and loss of sleep are largely due to this symptom. Demulcent 
drinks, as flaxseed tea, infusion of slippery-elm bark, or solution of gum 
Arabic, are useful, to which, to render them more palatable, lemon-juice may 
be added. A small Dover's powder or the mistura glycyrrhizse composita 
of the Pharmacopoeia, given occasionally, relieves the severity and diminishes 
the frequency of the cough. 

As the chief danger in measles is from inflammation of the respiratory 
organs, local treatment directed to the chest is important. The chest should 
be covered with cotton wadding or in cold weather even oil-silk, unless in 
the mildest cases. This increases the amount of eruption upon the surface 
underneath, and, I believe, tends greatly to prevent complication by capillary 
bronchitis and pneumonia. If the eruption be tardy in its appearance or 
indistinct, it is well to produce moderate counter-irritation by some gentle 
irritant underneath, as camphorated oil, to which in older children a little 
turpentine may be added. 

AiFections which complicate measles should receive, for the most part, 
such treatment as is appropriate for them when idiopathic. Secondary dis- 
eases, however, require sustaining measures more than primary. In bronchial 
and pulmonary inflammations — which if they occur early in measles prevent 
the regular appearance of the eruption, or if in the eruptive stage cause its 
disappearance — prompt counter-irritation over the chest by sinapisms or other- 
wise is required. Trousseau states that he has derived benefit in these cases 
from what he designates urtication. This is produced by stroking the chest 
two or three times daily with the nettle ( Urtica dioica or Urtica urens). This 
causes a prompt and abundant eruption, and with a less amount of suff"ering 
than one would suppose. The fever abates, and the respiration becomes 
more natural in proportion to the amount of nettlerash. On the second day 
the eff"ect is less than on the first, and after three or four days, says Trous- 
seau, no further irritation results from the nettle. When counter-irritation 
is produced, by whatever method, the chest should be covered with a warm 
and soft poultice, as the ground flaxseed ; derivatives to the extremities are 
useful in such cases. In capillary bronchitis and pneumonia stimulating 
expectorants are required, as carbonate of ammonium. I frequently write 
the following prescription. It is useful both as an expectorant and cardiac 
stimulant. Given in milk or after food is taken, it does not produce gastritis, 
as it often does in a more concentrated form : 

R. Ammon. carbonat., gr. xvj-:^ss; 

Aquae purae, ^ij. 

Give one teaspoonful in three or four of milk every hour or two. 

Chloride of ammonium is also a good remedy in these cases, employed in 
double the dose of the carbonate. 

Quinia to reduce the fever and digitalis or strophanthus or camphor as a 



ETIOLOGY. 271 

heart tonic are also very useful in these inflammations, given alone or alter- 
nately with the above. 

The cases of gangrenous vulvitis alluded to above were treated with a flax- 
seed poultice, and iodoform dusted over the surface each day or second day, 
with a satisfactory result. As regards the treatment of other complications 
the appropriate measures are detailed elsewhere. 



CHAPTER II. 

SCAELET FEVER. 

It is supposed by some who have studied the history of scarlet fever that 
it is of ancient origin, but the descriptions of diseases left us by the old writers, 
and by those in the Christian era until after the Middle Ages, are so obscure 
or differ so widely in the statements made from the symptoms of scarlet fever 
as it occurs in modern times that the impartial critic fails to find any clear 
evidence of its occurrence prior to the last four or five centuries. 

The first clear and undoubted portrayal of this disease is found in the 
medical literature of the sixteenth century. Sydenham and his contemporaries 
in the seventeenth century witnessed epidemics of it and studied its nature 
more thoroughly, and consequently acquired a more accurate knowledge of it 
than that possessed by their predecessors. It was in this century that measles 
and scarlet fever were differentiated. During the last two hundred years 
scarlatina has been the subject of monographs too numerous to mention. It 
has long been regarded as one of the most important maladies of childhood, 
on account of its frequency and the great mortality that attends it, so that 
numerous cases and many epidemics are every year related in the medical 
journals. By this vast accumulation of observations and the patient and 
thorough use of the microscope our knowledge of scarlet fever has become 
full and accurate. 

As with most of the infectious maladies, scarlet fever was introduced into 
the Western Hemisphere by European navigators. It was brought to North 
America about the year 1735. Tardily it spread to South America, where it 
appeared in 1829, and more recently it has been established in Australia. 
It entered Iceland in 1827 and Greenland in 1847. 

Etiology. — As yet, observers do not agree in regard to the parasite 
which is supposed to sustain a causal relation to scarlet fever. Klebs states 
that it is highly probable that both measles and scarlet fever are produced by 
micrococci, and he has sketched the design and described the development of 
a microbe which he designates the Monas scarlatinosum. 

The London Medical Times and Gazette for Jan. 28, 1882, contains an 
account of the supposed discovery of the scarlatinous microbe by Eklund of 
Stockholm, an authority in the microscopic examination of parasites. He 
says that scarlet fever is rarely absent from the Swedish capital and from 
the barracks and dwellings on the isle of Skeppsholm. In the urine of scar- 
latinous patients he has constantly found a prodigious number of discoid cor- 
puscles, oval or round, their diameter being less than y qVo iiiillimetre, and 
from -^ to jIq that of a red blood-cell. They are colorless or yellowish-white, 
surrounded by a distinct cell-wall, each containing a well-defined nucleus of a 
deeper hue. Sometimes one, sometimes more, of them are seen in the field 
of the microscope. They exhibit rotatory or oscillatory movements, especially 



272 SCARLET FEVER. 

observed when a drop of water is added to the fluid. They multiply, as 
Eklund has frequently seen, by fission — first in the microbes, next in the 
nucleus, and lastly in the cell-wall. He cannot say whether they develop 
into a mycelium. At any rate, the development of fine filaments seems to 
be exceptional. He has never seen them adhere in moniliform chains nor 
massed as zoogloea. He considers them to be veritable schizomycetes, and 
proposes the name Plox scindens. 

Eklund asserts that he has found these organisms in vast numbers in the 
soil- and ground-water of the isle of Skeppsholm, in the mud of the trenches 
dug for the water-mains, and in the greenish mould upon the walls of the old 
barracks, where scarlet fever was most rife. He states that scarlet fever has 
occurred in children after drinking milk mixed with the ground-water of the 
island, and he observed a case which followed immersion in one of the trenches 
of the island and the drying of the clothes in a small room. In another 
instance scarlet fever broke out in a block immediately after exposure of the 
ground-water by excavations. It is evident that the discovery of this microbe 
under such circumstances does not prove that it is the cause of the disease. 
This can only be determined by inoculation or by experiments which furnish 
the conditions of scientific exactness. In 1886, Dr. Edington of Edinburgh 
isolated a diplococcus and a bacillus from the blood and epidermis of scarlat- 
inous patients. He states that inoculation of the bacillus in rabbits caused 
erythema, followed by desquamation. But these observations, as detailed in 
the Lancet., show possible sources of error, and have therefore attracted but 
little attention. 

Dr. E. 0. Shakespeare describes the bacillus scarlatinas of Edington as 
"rods measuring 0.4 m. in thickness and 1.2 m. to 1.4 m. in length, most 
usually forming excessively long-pointed and curved leptothrix filaments, 
motile ;" and he remarks, " it is pretty well proven that this bacillus scarlatinas 
is the specific cause of scarlet fever." ^ 

Whatever may be the micro-organism which causes scarlet fever, its mode 
of action and effects have been ascertained by clinical observations. Without 
doubt, it commonly enters the system by the breath, but it probably may 
enter in the ingesta and it infects the blood. That it resides in the blood has 
been ascertained by inoculation with this liquid, by which scarlet fever has 
been reproduced in its typical form. From the blood it enters the tissues 
and secretions. Hence handkerchiefs or linen containing the saliva or mucus 
of a patient, the epidermic scales shed abundantly in the desquamative period, 
and probably also the urinary and fecal evacuations, contain the poison, so as 
to be highly infectious. Even the discharge of a scarlatinous otorrhoea is 
thought by some to be contagious for a considerable time. 

Scarlatina is communicable not only by direct exposure to a patient, but 
also by exposure to objects which happen to be in his room during his illness, 
and to which the poison becomes attached, such as clothing, books, and toys ; 
small packages, as we have stated above, sometimes convey and disseminate 
the contagious principle. 

In England observations have been made which show that scarlatina has 
been communicated by infected milk. The disease occurred in the family of 
a milkman, and the milk, before it was distributed, remained for a time in a 
kitchen which had been occupied by the patients. This milk was taken by 
twelve families, and in six of these scarlatina occurred almost simulta- 
neously at a time when few cases were occurring in the locality. There had 
been no direct exposure to the carrier of the milk nor to members of the 
affected family (Taylor). In another instance a woman and her son had 
scarlet fever while they were serving milk to several families, and the disease 
1 Annual of Med. ScL, vol. v., 1888. 



ETIOLOGY. 27 S 

appeared in all these families except one, which consisted of old people (Bell). 
It is known that milk absorbs volatile substances so as to be flavored by them, 
as is shown in the experiment of placing it in an open vessel in a box with a 
pineapple ; and it may in a similar manner become infected by the specific 
principle of scarlet fever, or it may be infected by detached particles of epi- 
dermis ; which is not improbable when one convalescing from scarlet fever is 
allowed to milk the cows or prepare the milk for distribution. In 1885 an 
epidemic of scarlet fever in London was traced to the milk-supply coming 
from a certain dairy in Hendon. The health officer of Hendon discovered a 
contagious disease in the cows of this dairy communicable to healthy cows 
by inoculation from the teats, and also communicable to man. The symp- 
toms in the cow were fever, cough, sore throat, discharge from nostrils and 
eyes. Communicated to man, the disease produced malaise, and in four or 
five days a vesicle. Crookshank believes that the Hendon disease was the 
Jennerian cowpox, and the symptoms certainly bore a closer resemblance to 
cowpox than to scarlet fever. Probably, therefore, the scarlet fever in Lon- 
don originated from some other source (^London Lancet). 

The scarlatinous virus surpasses that of any other eruptive fever except 
smallpox in its tenacious attachment to objects and its portability to distant 
localities. Hence in the literature of the disease are the records of many 
cases in which the poison was conveyed long distances, retaining its virulence 
to the full extent and causing an outbreak of the malady in the localities to 
which it was carried. In New York, so frequently has scarlet fevor as well 
as measles and diphtheria been contracted from the persons or clothing of 
well children who come from infected houses, that the Health Board now 
exclude from the public schools all children who come from such houses, even 
though they live on separate floors from those occupied by the sick. In one 
instance that came under my notice a washerwoman whose child had scarlet 
fever communicated the disease to an infant in the household where she was 
employed, by placing her shawl over the cradle in which it was lying. A 
physician of my acquaintance went from a scarlet-fever patient to a family 
several streets distant, and took one of the children upon his lap. After 
the usual incubative period this child sickened with a fatal form of the mal- 
ady, and the remaining children of the household were in time aff'ected. In 
New York scarlet fever has seemed to me to be not infrequently communi- 
cated through school-books, which, profusely illustrated by pictures and ren- 
dered attractive to the young, are often allowed to lie upon the bed of a scar- 
latinous patient, and be handled by him during convalescence or even during 
the course of the fever if it be mild. The young librarian of the circulating 
library of a Sunday-school, whose pupils came largely from the tenement- 
houses, was occupied a considerable part of a day in covering and arranging 
the books. After about the usual incubative period of scarlet fever he sick- 
ened with the disease. His two sisters were immediately removed to a rural 
township three- hundred miles away, and to an isolated house where scarlatina 
had never occurred. About one month after his recovery, and after his room 
had been disinfected by burning sulphur and his bedclothes and linen had 
been thoroughly washed, and all articles suspected to hold the poison had 
been either disinfected or destroyed, the brother visited his sisters in the 
country. Three weeks subsequently to his arrival one of these sisters sick- 
ened with scarlet fever, and a week later the other also. It seems that the 
exposure must have occurred several days after his arrival in the country 
from some books or other infected article in his possession. About two 
months elapsed after the last case ; the family had returned to the city, the 
infected room in the country-house had been thoroughly fumigated by burn- 
ing sulphur from morning till evening, when a little girl from an inland city 
18 



274 SCARLET FEVER. 

remained a few days in this liouse. and probably often entered the room where 
the young ladies had been sick. In a few days she also sickened with a fatal 
form of scarlatina. Such histories and experiences are not infrequent. They 
are common during epidemics of scarlet fever. They indicate an extraordi- 
nary attachment of the scarlatinous poison to objects, and show that it is not 
gaseous nor readily volatilized. 

A striking example of this fixity of the poison occurred in the practice 
of the late Kearney Rogers, formerly a prominent and much-esteemed sur- 
geon of New York City. Six children in a family had scarlet fever. Three 
and a half months subsequently another child, living at a distance, was 
allowed to return home and occupy the apartment in which the sickness had 
occurred. One week subsequently to the date of the return this child sick- 
ened with the same malady. Elliotson states that a patient with scarlet fever 
was admitted into one of the wards of St. Thomas's Hospital, and for two 
years subsequently young persons who were admitted into the ward were apt 
to take the disease. Richardson of London relates the following experiences 
of a family whom he attended in the rural district : " At a short distance 
from one of our villages there was situated on a slight eminence a small 
clump of laborers' cottages, with the thatch peering down on the beds of the 
sleepers. A man and his wife lived in one of these cottages with four 
lovely children. The poison of scarlet fever entered the poor man's door, 
and struck down one of the flock." The remaining children were now 
removed some miles away, and after several weeks one of them was allowed 
to return. Within twenty-four hours he also took the disease, and quickly 
died. The walls of the cottage were now thoroughly cleaned and white- 
washed, the floors scoured, and all the wearing apparel either destroyed or 
washed. Four months elapsed after the last sickness when one of the 
remaining children returned. " He reached his father's cottage early in the 
morning; he seemed dull the next day, and at midnight I was sent for, to 
find him also the subject of scarlet fever. The disease again assumed the 
malignant type, and this child died." Richardson believes that the contagion 
was attached to the thatch, which could not be thoroughly disinfected. The 
fact of this remarkable long-continued attachment of the poison to objects, 
indicating by this fixity that it is a solid, is consonant with the theory that 
it is an organism. 

Incubative Period.- — The duration of the incubative period varies in 
difi'erent cases. It is sometimes less than twenty-four hours, as in the above 
case reported by Richardson ; in the following well-known case, observed by 
Trousseau, it was one day : A girl arrived in Paris from Pau, where there 
was no scarlet fever, and occupied the same apartment with her sister, who 
was sick with this disease. Twenty-four hours after her arrival she was also 
attacked with the same malady. 

Russeberger attended a child who was exposed at noon to scarlet fever, 
and took the disease on the following night. B. W. Richardson (^Clinical 
Essays., 1861, vol. i. p. 94) gives his own experience. He had applied his 
ear to the chest of a patient suff"ering from scarlet fever, and was conscious 
of a peculiar odor emitted from the patient. He was immediately nauseated 
and chilly, and from that moment he dated the beginning of an attack of 
scarlet fever. In the Transactions of the Clinical Society of London, vol. 
ix., 1878, the late Charles Murchison gives the statistics of 75 cases showing 
the incubative period, as follows : 

Jn 4 cases it was not more than 24 hours. 

" 2 " " " " 30 " 

'' 3 '' " " " 36 " 



COyTAGIOUSXESS. 275 

In 4 cases it was not more than 40 hours. 

" 1 " " " " 41 " 

- 4 " " " " 58 *' 

" 1 " '' '^ " 54 " 

'' 1 " " " '' 2}> days. 

" 31 cases it was within (time not accurately ascertained) ... 4 " 

" 2 cases the incubation did not exceed 4J " 

" 17 " " " " " 5 '' 

'' 2 '• " " " " 6 " 

In 3 cases Murchison believes that the incubation was precisely fixed at 
thirty-six hours, three days, and four and a half days. 

Watson says that a man reached Devonshire at mid-day to see his daugh- 
ter, who had scarlet fever. Two days later he was also attacked. Rehn saw 
a child who was attacked two days after its grandmother returned from a 
case of scarlet fever; and Zengerle, a girl of ten years, residing at Wangen, 
where there was no scarlet fever, who took the disease two days after her 
mother had returned from visiting a family affected with it. Loochner states 
that a boy aged four and a half years was attacked one and a half days after 
admission into the infected wards of a hospital. Armistead, in his annual 
report on the health of the Newmarket rural district, states that three chil- 
dren, coming from a different part of the district, visited Wesley, and stayed 
next door to a child who had had scarlet fever six weeks previously, and who 
was allowed to play with these children on the evening of August 13th and 
morning of the 14th. The family then returned home, and on the 18th, 
four days after the exposure, all three children sickened with scarlet fever 
(^British iMed'ical Journal, September 30, 1882). 

Ordinarily, therefore, the incubative period, though varying in different 
cases, is within six days. Many cases, however, occur in which it seems to 
be longer. Thus, in my practice scarlet fever appeared in a family on April 
26, 1882. The patient was immediately removed to the third floor and the 
other children to the basement. All communication between the infected 
room and the basement was forbidden, but on May 8th, twelve days after 
the separation, one of these children sickened with the disease. Many 
observers, among whom may be mentioned Niemeyer and Copland, believe 
that the incubative period may be longer than one week, but on account of 
the subtlety of the poison and the many modes of transmission, it is possi- 
ble that in the instances of an apparently long incubative period there were 
other and unsuspected exposures. When scarlet fever has been communi- 
cated by inoculation, as in the experiments of Rostan and others, the incu- 
bative period has been about seven days, but Gerhardt states that a man was 
attacked four days after an abscess was opened by a knife used upon a scar- 
latinous patient. This variation in the incubative period, which also occurs 
in some other infectious diseases, as diphtheria, is probably due mostly to 
individual differences, some being more susceptible than others ; but it may 
be due partly to those obscure meteorological conditions which we desig- 
nate the epidemic influence. Probably, as a rule, when the disease is 
quickly developed after exposure the attack is more severe than when 
several days elapse. 

Contagiousness. — The area of the contagiousness of scarlet fever is 
small : it apparently embraces only a few feet. Therefore, close proximity 
is the necessary condition of its propagation. Hence many who are exposed, 
particularly of those who are remotely exposed, do not contract the disease. 
There is also an idiosyncrasy in some children, so that they resist infection 
even when repeatedly and closely exposed. In the JVeio York Medical Record 
for March 23, 1878, C. E. Billinsrton states that of 90 children in 26 families 



276 SCARLET FEVER. 

who were exposed to scarlet fever, 43 contracted the disease and 47 escaped ; 
whereas, as is well known, comparatively few unprotected children escape 
pertussis, variola, varicella, or measles if exposed to either of these diseases. 
By strict isolation, therefore, the spread of scarlet fever is more easily pre- 
vented than that of most other acute infectious maladies. In the New York 
Foundling Asylum for a number of years children with scarlet fever were 
isolated in a small room attached to one of the wards. The door between 
the two rooms was closed, and not opened during the continuance of the 
sickness. Entrance into the small room was through another door, and a 
nurse was assigned to the scarlet-fever cases, with strict directions that she 
should not mingle with the other children. These simple precautions were 
found sufficient in the various epidemics of scarlet fever which occurred in 
the city to prevent the spread of the malady through this institution ; 
whereas, similar measures were much less effectual in arresting the spread 
of measles and pertussis. Consequently, an outbreak of scarlet fever in this 
institution was usually limited to a few cases, while the extension of measles 
and pertussis was arrested with difficulty till a more efficient quarantine was 
established. 

Variations in Type. — The type of scarlet fever varies greatly in different 
epidemics, and frequently also in cases which occur in the same epidemic, 
even in the same family. One child may have scarlatina so mildly that little 
treatment is required and convalescence soon begins, while another has the 
malignant form, and soon succumbs, notwithstanding the prompt employment 
of the most efficient and appropriate measures. Ordinaril}^, however, if the 
first case in a family be very severe, subsequent cases will present a similar 
type ; but there are notable exceptions. This variation in type in different 
years and different epidemics is probably not equalled in any other infectious 
malady. Consecutive epidemics may present this variation, or the same type 
may' continue for a series of years, and then, from some unknown cause, 
change to one milder or more severe. In England, during Sydenham's life, 
scarlet fever was so mild that he regarded it as a trivial affection, requiring 
little attention, like rotheln of the present time ; but after the death of 
Sydenham, Morton and his contemporaries in London found, to their sorrow, 
that the type of scarlet fever was very different from that described by 
Sydenham's pen. The late Dr. Graves of Dublin and his contemporaries 
treated a mild type of scarlet fever with a very small percentage of deaths 
• — much less than that during the preceding generation — and they attributed 
their success to their greater knowledge and more appropriate use of remedies 
than their ancestors possessed and employed. By and by the type changed, 
the mortality of former years was restored, and they discovered that their 
previous success in saving life had been due not to th^ir skill, but to the mild 
form of the malady. A distinguished physician of New York treated more 
than fifty cases of scarlet fever in one of the institutions without a single 
death. A few months afterward the type of the malady changed, and his 
own son perished from it. 

Surgical Scarlatina. 

After surgical operations, and sometimes in surgical cases not requiring 
operative measures, a scarlatinous efflorescence occasionally appears upon the 
whole or nearly the whole body, and remains for several days. The follow- 
ing were cases of the kind alluded to. They occurred in Guy's Hospital, and 
were published by H. G. Howse in Gm/s Hospital Reports for 1879: On 
March 15, 1878, Jacobson performed osteotomy upon a child suffering from 
extreme rachitis. The operation was followed by a moderate febrile move- 



SURGICAL SCARLATINA. 277 

ment (100° to 101°), and after three days by the appearance of an efflores- 
cence, with sore throat and the strawberry tongue. The osteotomy had been 
performed under carbolic-acid spray and with all the details of antiseptic 
surgery. The rash soon faded, the temperature fell, and the child, tempo- 
rarily separated from the other patients from the suspicion that the disease 
was scarlet fever, was brought back to the ward. The subsequent history 
confirmed the diagnosis of scarlet fever, for the skin desquamated, and on 
April 1st abundant albumen was found in the urine. The case terminated 
favorably. Three months previously the same operation had been performed 
on the other leg, with no unfavorable symptoms. On April 5th, three weeks 
after the osteotomy, a lipoma was removed from another patient aged twenty- 
one years. The following day the temperature rose to 101°, and remained 
at that till April 8th, when it suddenly increased to 103°, and a rose-rash 
occurred over the body, with sore throat. On April 9th, Howse excised the 
elbow-joint of a girl of sixteen years having pulpy disease. On the 10th 
her temperature began to increase, and on the 11th reached 105.8°. Toward 
evening a roseoloid eruption appeared over her body, and she was isolated. 
On April 12th, Dr. H. excised a fibroid bursa patella:? from a woman of twenty- 
nine years. On the following day her temperature was 99°, but on the 14th 
it rose to 100°. and on the evening of the 15th she had rigors and headache. 
On the morning of the 16th the temperature was 102.5°, and a roseoloid 
eruption occurred over the face and chest. The surgeons now perceived that 
an epidemic of the so-called surgical scarlatina was occurring, so as to justify 
the postponement of other operations. 

In the same volume of Guys Hospital Reports., James F. Goodhart gives 
the histories of nearly thirty cases of this disease occurring during a series 
of years in the same hospital. The patients were chiefly children, having the 
most diverse surgical ailments, among which may be mentioned hip disease 
and abscess, genu valgum without operation, necrosis of femur, hydrocele 
with explorative operation, a scald, a sinus over the great trochanter, spinal 
disease with abscess, tenotomy for club-foot, and vesical calculus with opera- 
tion. The most common disease was caries or necrosis with abscess. In 
cases operated on the intervals between the operations and the occurrence of 
the efflorescence varied from two days to more than two weeks. Goodhart, 
after a careful examination of these cases, came to the conclusion that they 
were for the most part examples of true scarlet fever, especially as a consid- 
erable proportion of them occurred in groups, and there was a known exposure 
of some of the patients to children admitted into the hospital with the sequelae 
of scarlet fever. 

In the British Med. Jour, for Jan., 1879, George May. Jr., reported a case 
of efflorescence in surgical practice which appears to have been scarlatinous. 
A child was operated on for the radical cure of hernia on Dec. 4th. Toward 
the close of the same day he became restless, vomited, and his pulse on the 
following day rose to 136. Forty-eight hours after the operation a rash 
appeared on the chest and arms, the abdomen became tense and painful, and 
on the following day he died. The poison, however, in this case may have 
been septic. 

Hillier remarks (^Diseases of Children) : " In the hospital for sick children, 
of the children who contract scarlatina a very large proportion have been the 
subjects of a surgical operation within a week before the rash appears.*' Gee 
says (Reynolds's Si/stem of Medicine) : "It has been doubted by some whether 
the scarlatiniform rash which sometimes follows operations is really scarlatinal. 
The eruption appears from the second to the sixth day after the operation, 
and, in the cases which have caused the doubt, is very fugitive and the 
first and only symptom. Yet that the disease really is scarlet fever would 



278 SCARLET FEVER. 

seem to be proved by the following observations : first, that the disease occurs 
in epidemics ; secondly, that in a given epidemic a severe case occasionally 
relieves the monotonous recurrence of the very mild form; thirdly, that a 
precisely similar scarlatinilla attacks in the same epidemic patients who have 
not been subjected to operation and who have no open sores; and lastly, by 
way of a veritable experimentum crucis, that, however freely the patients are 
exposed to ordinary scarlet-fever contagion afterward, they do not contract 
that disease." Paget and other distinguished London surgeons who have 
observed this complication of surgical cases believe that the patients have 
been previously exposed to the scarlatinous poison, and that the surgical dis- 
eases or operations furnish favorable conditions for the occurrence of scarlet 
fever, so that the exposure, which probably would have been without result 
in ordinary health, causes an outbreak of the malady. 

Those who have reported cases of this form of efflorescence have for the 
most part neglected to state whether the patients had had scarlet fever pre- 
viously, knowledge of which would have aided in the diagnosis ; but from an 
examination of the histories of cases, especially those published in the London 
journals in the last four or five years, there can, I think, be little doubt that 
surgical maladies of a certain kind, especially traumatism, do produce a state 
of system which predisposes to scarlet fever, so that this class of patients are 
especially liable to contract it. Therefore, in my opinion, a considerable pro- 
portion of reported cases of surgical scarlatina are genuine, but in a consider- 
able number, perhaps an equal number, of such cases the histories and symp- 
toms indicated a septic rather than scarlatinous efflorescence, and in not a few 
instances, when consultations have been held, opinions diifered, some diagnos- 
ticating scarlet fever, others septicaemia. In some of the cases I find it stated 
that the fauces presented the normal appearance. Now, faucial redness is so 
generally present in scarlet fever, antedating that of the skin and coexisting 
with it, that its absence is strong evidence that the disease is not scarlatinous. 
Moreover, when, as was true of certain of the reported cases, the rash appeared 
irregularly upon the surface, and faded away in two or three days with the 
abatement of the fever, and the conditions of septic absorption were present, 
the efflorescence was probably septicaemic. 

The following were apparent]}^ cases of septicaemic efflorescence : A child 
aged five years (Brit. Med. Jour.^ Feb. 15, 1879) had inflammation of the 
lymphatic glands in the groin, which suppurated. At the time when the 
abscess was fully formed a rash appeared over the entire body. It consisted 
of numerous red points, but was paler than that of ordinary scarlet fever; 
temperature never above 99° ; no sore throat nor desquamation of cuticle. 
No child exposed to her took scarlet fever, and her sickness could not be 
traced to infection. In the British 3Ied. Jour.., Jan. 4, 1879, L. Braxton 
Hicks states that his son, attending school at Reading, was seized with a 
severe attack of pyrexia, accompanied on the second day by delirium and the 
occurrence of a rash like scarlet fever over the entire surface. He had no 
decided redness of the fauces, though it was perhaps slightly flushed. The 
right buttock was swollen from inflammation, and a large, deep-seated abscess 
formed near the tuberosity of the ischium. When the delirium abated the 
boy said that he was standing the day before the fever began with his legs 
far apart, when a schoolfellow stretched them farther by suddenly pulling on 
one of them. The rash, which was nearly universal, lasted three days, and 
was not followed by desquamation. No case of scarlet fever occurred in the 
school before or afterward. In the same volume of the British Medical Jour- 
nal^ Surgeon Frolliott, of the East India Service, relates the case of a private, 
aged twenty-three years, and three years in India, who, when on duty in the 
Punjab, was injured by the explosion of an Afghan powder-magazine. The 



OBSTETRICAL SCARLATINA. 279 

accident occurred Dec. 21, 1878. On Dec. 25th a bright scarlet rash appeared 
upon the abdomen and spread over the entire body. The following day the 
eruption was very vivid, like a boiled lobster, and it lasted five days. The 
temperature, which in the beginning had been 101°, abated to the normal 
after the rash appeared. No soreness of throat nor redness of the buccal sur- 
face occurred, but the epidermis desquamated, even from the palms of the 
hands and soles of the feet. Now, the febrile movement of scarlet fever does 
not cease while the efflorescence is distinct. It does not even diminish when 
the eruption appears, while in the above case it fell to the normal — a common 
occurrence in septicaemia, even when the blood-poisoning is profound. More- 
over, scarlet fever is so rare in India that Frolliott, after twelve years' service, 
had only heard of one case among Europeans and natives. The surgeons 
who consulted over the case of this private disagreed in opinion, some regard- 
ing the disease as septicsemic, others as scarlatinous. But a better knowledge 
of the clinical history of scarlet fever on the part of these army surgeons 
would, I think, have removed all doubt as to the diagnosis. 

It is the opinion of some reputable surgeons that the exposure of trau- 
matic patients to the scarlatinous poison sometimes aggravates the inflamma- 
tion of wounds, causing them to assume an unhealthy appearance, even though 
no scarlatina be produced. The late Dr. Solly made the remark, " Whenever 
a case of surgery in private practice takes on a highly phlegmonous appear- 
ance, I am always sure to find break out, in the inmates of the house, either 
erysipelas or scarlet fever" (^Britkh Med. Jour.^ Feb. 15, 1879). We will 
see that the scarlatinous poison sometimes causes pharyngitis or nephritis 
without producing the general disease. In a similar manner it seems that it 
may aggravate open wounds, intensifying the inflammation in them, while 
there is no efflorescence or other symptom to show that scarlatina itself is 
present. The poison appears to act entirely locally in such cases. 

Paget, in his Clinical Lectures^ says: " I think it not improbable that in 
some cases results occurring with obscure symptoms within two or three days 
after operations have been due to the scarlet-fever poison, hindered in some 
way from its usual progress." Playfair, in his remarks on the puerperal state, 
adds : " Mr. Spencer Wells informs me that he has seen cases of surgical 
pyemia which he had reason to believe originated in the scarlatinal poison ; 
and his well-known success as an ovariotomist is no doubt, in a great meas- 
ure, to be attributed to his extreme care in seeing that no one likely to come 
in contact with his patients has been exposed to any such source of infec- 
tion." Opinions like these, held by such prominent members of the profes- 
sion and sustained by many observations, should certainly induce physicians 
to prevent, as far as possible, exposure of their surgical patients, especially 
if they have sores or wounds, whether by traumatism or scalpel, to the scar- 
latinal poison. 

Obstetrical Scarlatina. 

Women during convalescence after childbirth are very liable to contract 
scarlet fever. In the New York Infant Asylum, which has maternity wards, 
a woman was admitted from a house in which scarlet fever was prevailing, 
and assigned to a cot next that occupied by one of the waiting-women, who 
was confined soon afterward. Her labor was favorable, but three days after- 
ward she took scarlet fever, and another lying-in patient contracted it from her. 
The sore throat and desquamation were characteristic. It has come to my 
knowledge that a physician of New York, in whose family scarlet fever was 
occurring, attended three women in succession in their confinement, and all 
contracted scarlet fever, which presented the characteristic symptoms, and two 
of them died. Experienced and cautious physicians of New York, aware of 



280 SCARLET FEVER. 

the danger, do not go directly from a scarlatinous patient to an obstetrical 
case, but avoid the risk by intermediate visits to other patients or by remain- 
ing for a time in the open air. As an additional precaution, I never attend 
a case of midwifery without first soaking my fingers in a solution of corrosive 
sublimate. 

Playfair, remarking on this subject, says : " There is good reason to believe 
that the contagium of zymotic diseases may produce a form of disease indis- 
tinguishable from ordinary puerperal septicaemia, and presenting none of the 
characteristic features of the specific complaint from which the contagium was 
derived. This is admitted to be a fact by the majority of our most eminent 
British obstetricians, although it does not seem to be allowed by continental 
authorities, and it is strongly controverted by some writers in this country. 
It is certainly difficult to reconcile this with the theory of septicaemia, and 
we are not in a position to give a satisfactory explanation of it. I believe^ 
however, that the evidence in favor of the possibility of puerperal septicaemia 
originating in this way is too strong to be assailable. The scarlatinal poison 
is that regarding which the greatest number of observations has been made. 
Numerous cases of this kind are to be found scattered through our obstetric 
literature, but the largest number are to be met with in a paper by Braxton 
Hicks. Out of 68 cases of puerperal disease seen in consultation, no less than 
37 were distinctly traceable to the scarlatinal poison. Of these, 20 had the 
characteristic rash of the disease, but the remaining IT, although the history 
clearly proved exposure to the contagium of scarlet fever, showed none of its 
usual symptoms, and were not to be distinguished from ordinary typical cases 
of the so-called puerperal fever. On the theory that it is impossible for the 
specific contagious diseases to be modified by the puerperal state, we have to 
admit that one physician met with 17 cases of puerperal septicasmia in which,, 
by a mere coincidence, the contagion of scarlet fever had been traced, and 
that the disease nevertheless originated from some other source — an hypothesis 
so improbable that its mere mention carries its own refutation." 

Parturition, like traumatism, furnishes in an eminent degree the conditions 
in which septic poisoning occurs, and the efflorescence which often accompa- 
nies septicaemia bears, as we have seen, a very close resemblance to that of 
scarlet fever. Hence in many instances the same difficulty is present in mak- 
ing a differential diagnosis between septic and scarlatinous blood-poisoning in 
obstetrical cases which occurs in surgical practice. But, according to my 
observations, an efflorescence occurring during the week following parturi- 
tion is in most instances septic. It is only in excej)tional cases that it is 
scarlatinous. But if, as Playfair believes, the scarlatinal poison sometimes 
produces in parturient women a puerperal fever in which the characteristic 
scarlatinal symptoms are lacking, and which, in the present state of our 
knowledge, is not distinguishable from ordinary septic fever, certainly the 
scarlatinous virus sustains a more frequent causal relation to childbed fever 
than has been heretofore supposed. 

Age. — Infants under the age of six months do not ordinarily contract 
scarlet fever, although fully exposed, and those under four months nearly 
possess immunity. Still, this disease has been observed in new-born infants, 
contracted, apparently, through the placental circulation. Tourtual states 
that a woman waited upon her own husband and child, both of whom had 
scarlet fever, during the eighth and ninth months of her pregnancy till near 
her confinement. Though she had no symptoms of scarlet fever, her infant 
had unusual redness of the skin and buccal surface and difiSculty of swallow- 
ing up to the fifth day. On the ninth day desquamation began, and at a 
later stage the nails of the fingers and toes separated. A case having a his- 
tory in some respects similar is related by Megnert, but the symptoms were 



CLINICAL FACTS REGARDING SCARLET FEVER. 281 

anomalous for scarlet fever, and the disease may have been ordinary septic 
fever. On the other hand, in one instance in my practice a mother had scarlet 
fever, beginning about the third day after her confinement, and although she 
suckled her infant and it was constantly in bed with her, it had no symptoms 
of scarlet fever, but became aiFected immediately afterward by a severe 
form of eczema, probably from the altered quality of the milk ; and in two 
instances observed by Murchison new-born infants remained healthy, although 
their mothers suffered from scarlet fever. 

After the age of six months the liability to scarlet fever increases till the 
close of infancy, children between the ages of six months and one year being 
less liable to contract the malady than during the second year, and those in 
the second year being less liable to it than those in the third year. Murchison 
collected the statistics of deaths from scarlet fever in England and Wales 
during a series of years ending with 1861. The number of deaths aggregated 
148,829, and the percentage of deaths at different ages was as follows : 

Deaths under 1 year G.7 per cent. 

between 1 and 2 years 14.09 " 

2 and 3 ' '' 16.00 " 

3 and 4 " 15.13 " 

4 and 5 " 11.9 

'' 5 and 10 " 25.9 '' 

'' 10 and 15 " 5.8 " 

'' 15 and 25 " 2.6 

'' 25 and 35 " 0.8 

over the age of 35 " 0.8 " 

Among the deaths were 10 cases above the age of 85 years, so that scarlet 
fever, though especially a disease of childhood, may occur in any decade of 
life ; but old age, like early infancy, almost possesses immunity from it. 

I have preserved the records of the ages of 145 consecutive cases occurring 
in private practice. If we add to these 58 cases observed by Prof. Octerlony 
{Artier. Jour, of Med. Sci., July, 1882), we have the statistics of the ages of 
203 cases, which are embraced in the following table : 

Under 1 year 3 

From 1 to 2 years 25 

" 2to 3 " 43 

" 3to 5 " 57 

" 5 to 10 " 53 

" 10 to 15 " 13 

" 15 to 20 " . 3 

" 20 to 30 " 4 

'' 30 to 40 " 2 

Total 203 

Clinical Facts regarding Scarlet Fever. 

As a rule, scarlet fever occurs but once, one attack conferring immunity 
from the disease for life ; but there are exceptions. In 1860, I attended a 
child with fatal scarlet fever who three years previously, it was stated, had 
passed through a first attack with all the characteristic symptoms. The fol- 
lowing case occurred in a family attended by the late Dr. Herzog : R , a 

boy of six years, had scarlet fever in a mild form in January and February, 
1875, followed by moderate desquamation. In July of the same year he was 
kicked by a horse in the street, receiving a deep scalp-wound which required 
stitching. Three days afterward he had, to appearance, a second attack 
of scarlet fever, attended by high febrile movement and followed also by 



282 SCARLET FEVER. 

desquamation. It was believed by Dr. H. to be a genuine case, and was so 
treated. I am not able to state as regards the presence of soreness of the 
throat, and doubt arises whether the second attack may not have been septi- 
csemic. In April, 1876, a third attack occurred, which I saw from the begin- 
ning. It was accompanied by all the characteristic symptoms — injection 
of the fauces, an efflorescence continuing the usual time, followed by des- 
quamation and albuminuria, the latter remaining several weeks. Kichardson 
states that three distinct attacks occurred in his own person, and a student 
attending the lecture at which this was mentioned informed the doctor that 
he also had scarlet fever three times. 

Sometimes a. second attack occurs so soon after the first that it has been 
described as a relapse. The following was a case in point in the practice of 
Godneff (Meditz. Vesfmk., No. iv., N. Y. Med. Bee, April 30, 1881) : A youth 
of seventeen years contracted scarlet fever while taking care of a child. It 
began with a chill, and he had the usual efflorescence, sore throat, and tume- 
faction of the cervical glands. An exudation appeared upon his tonsils and 
uvula, and his temperature reached 104°. The urine contained a trace of 
albumen ; the rash in due time faded ; and the epidermis exfoliated. On the 
fifteenth day, when he was about ready to leave the hospital, he again had a 
chill, followed by fever. The temperature reached 105.2°, the rash reap- 
peared over the entire surface except the face, diphtheritic exudations 
occurred upon the fauces, and the urine, the quantity of which was dimin- 
ished, again became albuminous. The second efflorescence faded on the 
twenty-fourth day, and on the twenty-seventh exfoliation began. Hillier 
says : " I have seen a young woman in the fever hospital suifering from a 
second attack of scarlatina, the first attack having occurred five weeks pre- 
viously. She had quite recovered from her first illness, and was acting as 
nurse. In both seizures the rash, the sore throat, and other symptoms were 
characteristic. The relapse or recurrence was less severe than the primary 
disease." Cases of a fourth attack, or even of a greater number, have 
been reported. The first seizure is sometimes milder, but in other instances 
is more severe, than those which follow. 

Exposure to the scarlatinous poison not infrequently produces pharyngitis 
without the occurrence of scarlatina, and the inflammation is usually severe, 
accompanied by pain in swallowing and marked febrile movement. This 
phlegmasia is distinguished from scarlet fever by its shorter duration and the 
absence of the efflorescence. It occurs in adults as well as in children, and 
in those who have had, as well as in those who have not had, scarlatina. So 
far as I have observed, it is very seldom accompanied or followed by any of 
the complications or sequelae so common in and after scarlet fever. It can- 
not be distinguished from ordinary pharyngitis except in the manner in which 
it occurs, and one attack does not preclude another. The late George B. 
Wood made the remark that he never attended a case of scarlet fever with- 
out suff"ering from sore throat. The following were examples of this form 
of pharyngitis : On Jan. 17, 1882, I was called to a boy of three years with 
severe scarlet fever, ushered in by convulsions. On the following day his 
sister, aged seven and three-fourths years, whom I had attended a year pre- 
viously during a severe attack of scarlatina, and who had been almost con- 
stantly with the brother, became very ill, with a temperature of 103.5°; 
Examination revealed severe inflammation of the fauces, without pseudo- 
membrane or any other exudation except muco-pus. On Jan. 19th an older 
brother, nine years, whom I had attended in scarlet fever three years pre- 
viously, was affected in the same way, his temperature being 104° and his 
respiration guttural and noisy, especially during sleep, in consequence of the 
great amount of faucial swelling. At times he was delirious. The inflam- 



SYMPTOMS. 283 

mation in botli cases began to abate about the third day, and had disappeared 
by the close of the week. That the contagium of scarlet fever may be 
received into the system and cause pharyngitis while the patient has immu- 
nity from scarlet fever through a previous attack, and that this inflammation 
may occur any number of times, as in the case of Dr. Wood, are remarkable 
facts. 

Now and then cases occur which appear to show that the scarlatinous 
poison may affect the kidneys, producing nephritis, while there is no other 
manifestation of its influence. Thus in my practice a lady of about forty- 
five years constantly attended her son, sleeping by his side, during an attack 
of scarlet fever. Her health had previously been good. When the boy was 
convalescent, as her appetite failed and she was indisposed, a careful exam- 
ination revealed the fact that she had albuminuria, although she had had no 
sore throat or other symptoms of scarlet fever. After several weeks of 
treatment her disease was removed, and she has remained well since. In the 
British Med. Jour, for Nov. 29, 1879, it is stated that in a family four girls 
were found to be sufl'ering from desquamative nephritis. One of them had 
recently had scarlet fever, but the other three had presented no symptoms 
whatever of this disease. Such cases, although probably rare, appear to 
show that, as the scarlatinous poison may produce inflammation of the fauces 
without the occurrence of scarlet fever, so it may cause nephritis without 
producing the general disease, or apparently disturbing the functions or 
changing the state of other parts, except the kidneys. 

Symptoms. — Ordinary Form. — Scarlet fever usually begins abruptly, 
so that the exact time of its commencement can be fixed. If any premoni- 
tory symptoms occur, they are slight, so as scarcely to attract attention, as 
languor or the appearance of fatigue. A dusky aspect of the surface may 
occasionally be obsei'ved during the few hours preceding the attack. In 
some children the first symptom is chilliness, and occasionally a distinct 
chill occurs. In the adult a chill is ordinarily the first symptom. With or 
without the initial chilliness fever occurs, of variable intensity according to 
the severity of the type, and accompanied by such symptoms as usually 
arise in a febrile state of system, as cephalalgia, anorexia, and thirst. The 
pulse rises to 110, 120, or more per minute, the temperature to 102°, 103°, 
or 104° ; the skin is hot, face flushed, and the eyes bright. Even in cases 
that are not malignant or grave, and that give indications of a favorable 
result, there is often more or less stupor, with transient delirium and sudden 
starting or twitching of the extremities, showing that the cerebro-spinal axis 
is involved. 

Vomiting is a common symptom in the beginning of scarlet fever, occur- 
ring before the appearance of the efflorescence. It therefore has diagnostic 
value when the nature of the case is still doubtful. In some patients it is 
an initial symptom, but in others some hours have elapsed when it occurs. 
I recorded its presence or absence in 214 patients, with the following result : 
present in 162 patients, absent in 52. In severe forms of the disease it is 
rarely absent, and if it do not occur it is probable that the case will be mild, 
requiring little treatment and having a favorable termination. In epidemics 
of unusual mildness the number of cases without vomiting may be in excess 
of those in which this symptom occurs. It appears to be due to functional 
disturbance of the cerebro-spinal system, and may therefore be properly 
regarded as a nervous symptom. In severe cases the vomiting is usually 
repeated, not only on the first but on subsequent days, and we shall see that 
in cases of great gravity, in which a fatal termination is not improbable, per- 
sistent vomiting, by which the food and stimulants so urgently required are 
rejected, interferes seriously with successful treatment. In a few cases 



284 SCARLET FEVER. 

embraced in my statistics nausea without vomiting was recorded. The bowels 
in ordinary scarlatina act regularly or are slightly constipated. Diarrhoea, 
which so commonly accompanies the persistent vomiting in malignant cases, 
if it occur in this form of the malady is slight and transient and due to acci- 
dental causes. The food, if it be given in the liquid form and cool, is usually 
taken readily on account of the thirst, except when deglutition is rendered 
painful by the pharyngitis. 

The symptoms pertaining to the nervous system vary according to the 
severity of the disease and the temperament of the patient. Many children 
during the progress of the common form of scarlet fever present a dull or 
apathetic appearance. They lie much of the time with their eyes closed ; 
others are more restless, and not a few, if the fever be considerable, have 
occasional twitchings of the limbs and more or less headache. Eclampsia 
sometimes occurs on the first day, especially in those predisposed to it, even 
when the subsequent course of the disease is mild and favorable. This com- 
plication, very grave and usually fatal when it occurs at a later stage, is in 
most instances, when it takes place on the first day, readily controlled by 
proper remedies and with little detriment to the patient. But if it be attended 
by high elevation of temperature and marked drowsiness, approaching the 
comatose state, it is very serious upon the first as well as upon the subsequent 
days. Nervous symptoms occurring in the beginning of scarlet fever, when 
it has the ordinary favorable type, begin to abate in three or four days, but 
if they supervene at a later date, and especially in the declining stage, they 
possess more gravity, since they then not infrequently result from and indi- 
cate renal complication. 

Early in the disease, nearly as soon as the commencement of the fever^ 
the faucial and buccal surfaces become inflamed, as shown by redness, swell- 
ing, and tenderness. The physician summoned in the beginning of an attack 
will already, at his first visit, observe hyperaemia of the fauces, with points 
of deeper injection than over the general faucial surface, and soon the buccal 
surface also participates. The inflammation at first produces preternatural 
dryness, and this is followed by a viscid secretion. The papilla© of the tongue 
enlarge and become prominent, giving rise to the appearance known as straw- 
berry tongue which is so common in scarlet fever. This state of the buccal 
and faucial membrane continues throughout the disease. A thin fur appears 
upon the tongue on the first day, and it increases on the second and third 
days, after which it is usually detached, exposing the surface of the organ, 
which has a deep-red hue, but in not a few patients the fur remains or is 
reproduced as soon as shed. Except in the mildest cases the Schneiderian 
membrane also participates in the inflammation as the disease advances, so 
that a thin, irritating discharge containing leucocytes or pus-cells flows from 
the nostrils. The skin is hot and dry and cutaneous transpiration is nearly 
checked. The respiratory system is rarely involved in any notable manner 
unless there be a complication. Many have no cough whatever, while others 
have a slight cough, due to the fact that the inflammation of a catarrhal form 
has extended from the fauces to the surface of the glottis. Slight accelera- 
tion of respiration, corresponding with the degree of fever, may also be 
observed. The kidneys commonly act regularly and normally during the 
first days, any serious impairment of their functions being rare before the 
close of the first week. 

When the symptoms described above have continued from six to eighteen 
hours the efllorescence appears. It is first observed about the ears, neck, and 
shoulders in reddish patches fading into the normal hue. These patches 
extend and unite, and in the course of a few hours the trunk and upper 
extremities, and finally the legs, are covered. The scarlatinous rash usually. 



SYMPTOMS. 285 

when fully developed, resembles that produced by external heat or the appli- 
cation of a sinapism. It has been likened to the appearance of a boiled lob- 
ster, but there are numerous minute points of a deeper or duskier hue than 
the surface generally. In many patients the rash appears, especially over 
the abdomen and lower extremities, as minute, thickly-set points, with the 
skin of normal appearance between them. Henoch of Berlin says of scarlet 
fever : " In general, the moderate grades of eruption prevail, the skin, when 
seen from a distance, presenting a diffuse, more or less scarlet redness, while 
on closer inspection it is found that this redness is composed of innumerable 
red points closely situated together, and separated from one another by very 
small paler portions of skin. The dark-red points appear to correspond to 
the hair-follicles." On passing the finger over the efflorescence no distinct 
prominences are observed, but a sensation of roughness is sometimes imparted 
from engorgement of the cutaneous papillae. The rash disappears on pres- 
sure, but it immediately reappears when the pressure is removed. Its slow 
return is evidence of sluggish circulation, and it indicates a grave and dan- 
gerous form of the malady. The color is then usually a dusky instead of a 
bright red. The efflorescence is most marked in dependent parts, as along 
the back, over the chest and abdomen, and in the flexures of the joints. 
Parts pressed upon by the bedclothes, which confine and intensify the heat, 
present a deeper coloration than other portions of the surface. _ Often, espe- 
cially in mild cases, the rash is absent from portions of the surface where it 
commonly appears, while it presents its typical character elsewhere. Tardy 
and incomplete establishment of the rash when the symptoms indicate an 
a,ttack of ordinary or more than ordinary severity is commonly due to some 
perturbating cause, especially diarrhoea. In the London Lancet for Aug. 16, 
1879, cases are related of supposed scarlet fever without the rash — cases in 
which pharyngitis and stomatitis with the strawberry tongue occurred, with- 
out efflorescence upon the skin ; but it is to be remembered, as stated above, 
that the inflammations which commonly attend or follow scarlet fever, par- 
ticularly the pharyngitis and nephritis, not infrequently occur in those who 
have already had scarlatina, and occur more than once from fresh exposure 
to scarlatina patients. These inflammations, occurring under such circum- 
stances, appear to be purely local maladies, produced by the scarlatinous 
virus ; and it seems to me a question whether, in the so-called scarlatina 
without efflorescence, the inflammations which are present, and which un- 
doubtedly have a scarlatinous origin, are not local in their nature, instead of 
being local manifestations of the constitutional disease. The burning and 
itching sensation produced by the rash increases the restlessness of the 
patient, and is sometimes the most annoying of the symptoms. 

The temperature in the common favorable forms of scarlet fever usually 
varies from 101° in the mildest cases to 103° or 104° in those more severe. 
If it attain 105° or over, the case is properly designated grave or severe. 
The febrile movement ordinarily fluctuates but little from day to day till the 
fourth or fifth day, when, if the case be favorable and no complication occur, 
it begins to decline. The temperature is as high in the beginning of the 
attack as subsequently. 

The symptoms pertaining to the digestive system during the initial period 
of scarlet fever have been sufficiently described. The subsequent symptoms 
referable to this system do not diff'er materially from those present in the 
beginning, except the absence of vomiting. The lips are dry and often 
cracked. The inflammation of the mouth and throat continues, with ano- 
rexia and thirst. With the decline of the disease the appetite gradually 
returns, but it is not till the close of the second week that it is fully 
Testored. G-reat and continued disturbance of the digestive apparatus, 



286 SCARLET FEVER. 

seriously interfering with the nutrition, pertains to the malignant forms of 
scarlet fever. 

The urine is high-colored, and in robust children during the first days of 
scarlet fever it frequently deposits urates on cooling. Gee, who has carefully 
investigated the state of the urine in scarlet fever, says that the quantity of 
water is diminished and the urea is not necessarily increased during the pyrexia ; 
that the chloride of sodium is diminished till the fourth, fifth, or sixth day ; 
and that the phosphoric acid is diminished during the climax of the pyrexia, 
though not in the first three or four days. In one case he made a daily esti- 
mation of the amount of uric acid, and found it greatly diminished on the 
second and third days, normal on the fourth, and much increased on the fifth. 
He believes that similar variations are common in the quantity of the prod- 
ucts excreted in the urine. Bile may also appear in the urine, coincident 
with a yellow tinge of the conjunctiva.^ 

The duration of scarlet fever varies in different cases. If the attack be 
very mild, with little efflorescence, the febrile movement may decline by the 
fourth or fifth day ; but if the disease be severe, little or no amelioration of 
symptoms may occur before the twelfth or fourteenth day, even when no com- 
plication has occurred to increase the temperature or cause aggravation of 
symptoms. Octerlony, who estimated the duration of scarlet fever from the 
commencement of febrile symptoms to " the disappearance of fever, with 
marked improvement in leading symptoms," . . . ."found that the average 
duration of the disease in forty cases was six and one-sixth days. The 
minimum duration in a very slightly marked case was three days : the maxi- 
mum duration was fourteen days." In general, prolongation of fever beyond 
the usual time is due to some complication — more frequently to unusually 
severe pharyngitis, with accompanying cellulitis, than to any other cause. 

The malady whose commencement was so abrupt declines gradually. In 
ordinary cases, by the close of the first week or in the beginning of the 
second the rash becomes less and less distinct, and finally disappears, as do 
also the redness and swelling of the buccal and faucial surfaces. The engorge- 
ment of the tonsils and of the papillae of the tongue subsides, the appetite 
returns, the countenance brightens and becomes natural, and the child, who 
during the height of the fever scarcely noticed objects or noticed them with 
indifference or even repugnance, can be amused as before his sickness. 

Desquamation succeeds. This begins at about the sixth day, and is not 
completed till the tenth or twelfth day, often not till the close of the third 
or in the fourth week. The amount of desquamation corresponds with the 
intensity and duration of the efflorescence, or rather of the dermatitis which 
produces the efflorescence. If the efflorescence have been slight and partial, 
it will be slight, perhaps scarcely appreciable, but if the rash have been gen- 
eral, full, and protracted, exfoliation occurs upon every part. It begins about 
the face and neck, and within a day or two appears upon other parts. Where 
the skin is thin the epidermis as it is detached presents a furfuraceous appear- 
ance ; where it is thick, as upon the palms of the hands or soles of the feet, 
it separates in layers of considerable thickness. 

Such is a brief description of scarlet fever when it pursues its normal 
course without any disturbing element, but there is no other disease in which 
complications and sequelae so frequently occur. The liability to them renders 
the prognosis in every case doubtful. They largely increase the percentage 
of deaths. They occur both in mild and severe forms of scarlatina. 

The difference in type in different cases and epidemics has already been 
alluded to. Scarlet fever is sometimes so mild and its symptoms so slight that 
the diagnosis is necessarily uncertain. In the spring of 1866, I was called 
^ Article on Scarlatina in Reynolds's System of Medicine. 



SYMPTOMS. 287 

to an infant thirteen months old who had slight pharyngitis and an indistinct 
rash over a part of the surface. In two days the eruption had disappeared, 
and the health within a day or two was apparently fully restored. Diagnosis 
would have been doubtful except for sequelae which clearly indicated the 
scarlatinous nature of the attack. In another instance two children passed 
through the entire course of scarlet fever, playing every day in the street. 
Although the intelligent grandmother saw the rash upon them, its nature was 
not suspected, as it was midsummer and cases of prickly heat common, till 
nearly two weeks afterward, when one of the children had nephritis and 
anasarca, ending fatally. In cases so mild as these the heat of the surface 
is but slightly increased, the pulse but little accelerated, and the rash usually 
does not occupy so much of the surface as in ordinary cases ; the appetite is 
not lost, though diminished, and the thirst is moderate. 

Between scarlet fever so mild that it terminates in four or five days, and 
that of the grave or malignant type presently to be described, all grades of 
severity exist. Scarlet fever occurs in all forms from mild to severe, but 
certain symptoms characterize grave or malignant cases — symptoms which 
are absent or much less prominent in ordinary scarlet fever. Therefore the 
grouping of cases according to the type is proper, and it facilitates the study- 
ing of the disease. 

Grave Form (malignant scarlet fever). — This form of the disease is in 
some epidemics common, while in others it is rare. The symptoms which 
characterize it are severe from the beginning, those of the nervous system 
predominating at first, such as intense cephalalgia, restlessness or stupor, 
sudden twitching of the muscles, and perhaps delirium or even convulsions. 
Many pass rapidly into coma and die within two or three days, succumbing 
to the intensity of the scarlatinous poison while the malady is still in its 
commencement. The rash is dusky. It disappears by pressure, and returns 
slowly when the pressure is removed, showing extreme sluggishness of the 
capillary circulation. Some patients are very drowsy, lying in a semi-comatose 
state except when aroused, and if aroused are very restless. Others are con- 
stantly restless. If placed in one position on the bed, they throw themselves 
in another in a half-conscious or unconscious state. They do not speak, or 
they mutter like those aff'ected by the graver forms of typhus, calling the 
names of playmates or talking incoherently about things which interested 
them when well. The theremometer placed in the axilla is found to rise 
above 103°, which is a safe average, to 105° or even 107°, and the heat of 
the surface is pungent except when the case approaches a fatal termination^ 
when the extremities, ears, and nose may be cool while the trunk and head 
are extremely hot. The pulse from the first is rapid, ranging from 130 as 
the minimum in a malignant case to a frequency which can scarcely be 
counted. A very frequent pulse is nearly always feeble and compressible. 
Irritability of the stomach is one of the most common symptoms in grave 
cases, so that many patients immediately reject the nutriment and stimulants 
which are so urgently required to sustain the vital powers. The vomiting, 
therefore, if frequent and severe, greatly increases the danger, and in not a 
few instances this symptom is associated with diarrhoea, which also tends to 
increase the prostration. 

Severe and dangerous nervous symptoms, due to the intensity or activity 
of the scarlatinous poison, occur chiefl}' within the first three or four days. 
Grrinding the teeth, sudden muscular twitching, delirium, convulsions, and 
profound stupor occur for the most part within this time. Afterward the 
danger is mainly from exhaustion, unless in the second week or subsequently, 
when nervous symptoms may arise from uremia. 

Those who survive the onset of malignant scarlet fever often have in the 



288 SCARLET FEVER. 

course of a few days severe pharyngitis, with extension of the inflammation 
to the lymphatic glands and connective tissue around the angle of the jaw. 
These inflammations cause more or less external swelling. The faucial tur- 
gescence around the entrance of the larynx, with the accompanying secre- 
tions of viscid mucus or muco-pus, often causes noisy respiration, and many 
at this stage of the attack breathe with the mouth constantly open to facili- 
tate the ingress of air. 

Ordinarily, no discharge occurs at first from the nasal surface, but as the 
disease continues, ^f the type remain severe, defluxion of thin muco-pus takes 
place from the Schneiderian surface, which excoriates the cheek. The lips 
also are frequently sore and swollen. 

In malignant cases the disease is more protracted than when the type is 
mild. Thus in a recent case in my practice the rash was still distinct at the 
close of the second week, though the temperature had fallen from 105° to 
102°, and some desquamation had appeared. Long continuance of the febrile 
movement is, however, oftener attributable to some inflammatory complica- 
tion than to the primary disease. 

In all epidemics of a severe type cases now and then occur in which the 
poison is so intense, or it acts with such frightful energy, that death occurs 
even within the first day. The patient is overpowered at the outset of the 
disease by the virulence of the specific principle, perishing in coma, preceded 
perhaps by convulsions. The autopsy in such cases reveals hyperaemia of 
the brain and cranial sinuses, blood of a dark-red color, capillary hemorrhages 
in various parts, a flabby heart, and perhaps some engorgement of the spleen 
and kidneys. 

Usually, malignant scarlet fever exhibits its severe type from the first, but 
cases sometimes occur which seem mild and favorable for a few days, when 
severe symptoms suddenly supervene. This change from a mild to a danger- 
ous disease is, however, most frequently, I think, due to some complication. 

Irregular Forms. — Deviation from the normal type in scarlet fever is 
usually due to some perturbating cause, which is often a pre-existing or 
coexisting disease or a disordered state of system through causes distinct 
from scarlatina. Thus, a little girl in my practice had the symptoms of 
scarlet fever, such as febrile movement and inflammation of the buccal and 
faucial surfaces, nearly a week before the scarlatinous eruption appeared. 
During this time the patient had an intestinal catarrh, with diarrhoea, which 
declined when the rash occurred. This intestinal disease was the apparent 
cause of the irregularity in the malady. If scarlatina occur during a severe 
attack of entero-colitis attended by purging, the defluxion from the intestinal 
surface may be such that no efflorescence appears. Severe scarlet fever itself 
sometimes appears to cause gastro-intestinal catarrh, so as to produce an afflux 
of blood toward the intestinal tract and away from the skin. Practitioners 
occasionally meet cases like the following, which I recall to mind : In a fam- 
ily where scarlatina was prevailing a little child early after the commencement 
of the symptoms which seemed to be plainly referable to this exanthem was 
seized with vomiting and purging, which continued till death occurred on 
the third day. No efflorescence appeared on the skin, but the symptoms 
indicated the presence of severe intestinal catarrh, complicating and masking 
scarlatina. We are aided in the diagnosis of such cases by observing the 
faucial redness, and we may discover a faint efflorescence upon parts of 
the surface, as about the groin or in the flexures of the joints. In another 
instance an infant in the warm months, having protracted entero-colitis, the 
usual summer epidemic of the cities, had the characteristic symptoms of scar- 
let fever, which was present in the family, but the diarrhcea continued and 
no rash appeared. 



COMPLICATIOSS AXD SEQUELS. 289 

In one who is much reduced by an antecedent disease, especially if, like 
the intestinal catarrh mentioned above, it produces a decided afflux of blood 
away from the surface and toward the interior of the body, the eruption is 
commonly tardy in its appearance, indistinct, or wholly absent. On the other 
hand, some maladies occurring in connection with this exanthem do not change 
its symptoms, but themselves undergo modification. Pertussis may be cited 
as an example, the cough of which is sometimes modified by an intercurrent 
attack of scarlet fever, the symptoms of the latter disease undergoing little 
change. 

Scarlet fever may also be irregular without any apparent perturbating 
cause. In 1867, I attended a young lady whose previous health had been 
good, and whose brother was sick at the time with scarlet fever. She had 
marked elevation of temperature, with severe pharyngitis, and. though her sur- 
face was repeatedly examined, no efflorescence was seen. Two weeks subse- 
quently she was affected with severe nephritis, anasarca, effusion into at least 
one of the pleural cavities, oedema of the lungs, and, according to my diagno- 
sis, hydro-pericardium, the case ending fatally. Rilliet and Barthez state that 
a second attack of scarlet fever is more likely to be irregular than the first. 
Probably this opinion is correct, especially if only a short time have elapsed 
between the two seizures. Still, as we have already stated, both seizures may 
be typical, and the second more severe than the first. 

It would be impossible to make a clear and positive diagnosis of certain 
cases of irregular scarlet fever, in which cerebral, pulmonary, or gastro-intes- 
tinal symptoms predominate, were it not for the fact that they occur in con- 
nection with other cases of scarlet fever or are followed by sequelae which 
evidently have a scarlatinous origin. 

Occasionally, the eruption, if it be intense or if a certain condition of sys- 
tem be present in the patient, is accompanied by more or less exti-avasation 
of blood-corpuscles from the capillaries, usually in points, so that the redness 
does not entirely disappear on pressure. In rare instances certain of the 
exanthematic fevers present an extreme hemorrhagic character, so as to be 
beyond the reach of remedies and of necessity speedily fatal. Hemorrhagic 
cases of this severe form are probably more common in variola than in the 
other fevers, but I have met a notable case in what was diagnosticated scar- 
latina. In June, 1881, a man in his thirty-second year, whose previous health 
had not been good, though he had no defined ailment and had been able to 
follow his occupation of harness-maker, suddenly became very ill, with great 
elevation of temperature and faucial inflammation, attended by marked pros- 
tration. After some hours an intense eruption of a scarlatinous appearance 
covered nearly the entire surface, and on the following day hemorrhages began 
to occur. The urine contained a large proportion of blood ; each conjunctiva 
was raised by hemorrhages underneath (ecchymosis), so that its natural color 
was lost, the eyelids were closed with difficulty, and blood flowed from the 
nostrils, gums, and under the skin, forming hemorrhagic points and blotches. 
One of the consulting physicians, perceiving the resemblance to hemorrhagic 
variola as described by Hebra, suspected that we had a case' of this formid- 
able malady to deal with, but the time for the appearance of the variolous 
eruption passed by without its occurrence. Death took place on the fifth 
day. The temperature during the sickness remained high, though the record 
of it has been mislaid. Fortunately, such severe hemorrhagic cases, which 
are necessarily fatal, are rare. 

Complications and Sequels. — Scarlet fever, if its type be severe, is in 
itself dangerous to life. Many, as we have seen, perish from its direct effects 
when it produces profound blood-poisoning. But, while the ordinary epi- 
demics of this malady are necessarily attended by a large mortality from the 
19 



290 SCARLET FEVER. 

virulence and depressing effect of the specific principle, unfortunately, of all 
tlie diseases of modern times, scarlatina ranks first as regards the number and 
gravity of its complications and sequelae, so that nearly or quite as many 
perish from these as from the direct effects of the poison. 

Nervous accidents occur chiefly at two periods — to wit, in the first days, 
when they are due to the severity and malignancy of the malady and to the 
impressible nervous temperament of the child ; and in the declining stage or 
after the termination of the fever, when they occur from uraemia. If the 
type be malignant, delirium, jactitation, profound stupor, and convulsions 
frequently occur on the first and second days ; and these are symptoms which 
properly excite the most alarm and demand all the resources of our art, since 
they indicate a form of the disease which frequently ends in speedy death. 
The eyes have a dull or wild expression, the conjunctiva is suffused, the heat 
of surface pungent, the pulse rapid and compressible or feeble, rising above 
150, even to 200, per minute, and the temperature is always elevated to a 
degree that involves danger, the thermometer not infrequently indicating 105° 
or 106°. But this severe form of scarlet fever, attended by so great eleva- 
tion of temperature, is much less dangerous than in former times, even though 
it be complicated by delirium and convulsions, since we no longer hesitate to 
reduce bodily heat, when excessive, by the free use of cold baths, and have 
discovered potent agents in the bromides and chloral for controlling convul- 
sions. Nevertheless, not a few perish in the commencement of scarlet fever 
with predominating cerebral symptoms, as delirium or eclampsia, followed by 
coma, under the best possible treatment. Sometimes the symptoms have 
closely simulated those of acute meningitis, and if the rash have been delayed 
and the sore throat is as yet slight, the physician may suspect that he is deal- 
ing with this disease ; but autopsies in such cases show no inflammatory 
lesions, but only congestion of the cerebral and meningeal vessels. 

As is stated in a preceding page, in every case of normal scarlet fever 
inflammation of the faucial surface is present, as indicated by redness, tender- 
ness, and increased secretion of mucus or muco-pus. It precedes the efflores- 
cence on the skin, and is announced by pain in swallowing and on pressure 
with the fingers behind and below the angles of the jaw. In that form of 
scarlet fever which has been designated anginose the pharyngitis is severe, 
and is a prominent element in the malady, the uvula, the pillars of the fauces, 
and the faucial surface in general being infiltrated and swollen. Neverthe- 
less, this inflammation, with the accompanying tumefaction, is properly a 
part of the disease, rather than a complication, if it abate with the subsidence 
of the scarlet fever or begin to abate soon after, and if it produce but slight 
destructive change in the tissue of the neck. The secretions from the fauces 
may be foul and offensive ; even superficial ulcerations or gangrene may occur 
upon the faucial surface, causing it to present a dark-brown or jagged appear- 
ance, and the tissues of the neck may be infiltrated to a certain extent, and 
we designate the disease a form of scarlet fever under the title anginose. But 
when this condition is greatly aggravated, so that extensive infiltration and 
swelling of the tissues of the neck occur, with an amount of ulceration or 
gangrene which in itself involves danger, continuing after the primary disease 
abates, prolonging the fever and reducing the strength, it is proper to regard 
the state of the throat as a complication. In addition to the pharyngitis, 
which is severe, as described above, the sides of the neck around the angles 
of the jaw become swollen, hard, and tender. The inflammation has been 
propagated to the deeper structures of the neck. Poisonous substances, the 
result of decomposition or vitiated secretions, traverse the lymphatic vessels 
from the faucial surface, and, being intercepted in the lymphatic glands, cause 
adenitis, and the inflammation extends from the glands to the adjacent con- 



COMPLICATIONS AND SEQUEL jE. 291 

nective tissue, which becomes hard, tender, swollen, and infiltrated with 
inflammatory products. This tumefaction sometimes begins by the second or 
third day, but it is usually about the close of the first week or in the begin- 
ning of the second week that it becomes so considerable as to constitute a 
source of danger and anxiety. It is in most cases bilateral, though one side 
may begin to swell before the other and remain larger throughout. 

In severe cases of this complication the tumefaction extends from ear to 
ear, filling up the space below and around the angles of the jaw and under 
the chin. Not only is deglutition difficult, but it is difficult to open the 
mouth sufficiently to inspect the fauces, and attempts to do so cause much 
pain. The lymphatic glands, which lie in the inflamed area and participate 
in the inflammation, are greatly enlarged by hyperplasia, the round granular 
lymph-cells multiplying so abundantly that the glands increase to many 
times their normal size. Most of the tumefaction is, however, due to exten- 
sion of the inflammation to the connective tissue of the neck. The cellu- 
litis, which resembles that occurring in other conditions, is attended by dis- 
tension of the capillaries, the abundant formation of young round cells, and 
transudation of serum (Billroth). A moderate amount of tumefaction may 
disappear by resolution, but if it be considerable it seldom abates in this 
way, but by the tedious and exhausting process of suppuration or gangrene. 
If the swelling at its most prominent point present a reddish hue, all hope 
of producing resolution must be abandoned ; it cannot be effected by any 
medicine or appliance within the resources of our art. The abscess which 
forms is likely to be diffuse, so as to involve danger of pyaemia, unless it be 
soon opened and properly washed out. With the discharge of the pus the 
swelling gradually softens and declines. In other cases gangrene results. 
The vessels in the inflamed part are compressed by the inflammatory prod- 
ucts, so that they no longer convey the blood which is required for the pur- 
pose of nutrition. It is a law of the economy that whenever the circulation 
ceases the tissues which receive their nutritive supply through the obstruct- 
ed vessels lose their vitality. Hence gangrene occurs in all that portion 
of the swelling in which the circulation is arrested. The skin over it peels 
off, the dead tissue underneath is brown or dark, and soon, if life be pro- 
longed, the slough begins to separate. The prognosis as regards this com- 
plication depends largely on the size of the slough. If it be large, death 
will probably result, since the strength of the system is already reduced by 
the primary disease, and the reparative process will necessarily be slow, 
while abundant suppuration tends to increase the exhaustion. In some 
of the worst cases of cervical gangrene which I have seen the slough has 
laid bare the muscles and vessels of the neck, producing in one case a cavity 
or excavation sufficiently large to admit a hen's egg. Often the slough 
extends under the skin, so that the deepest recesses of the cavity are not 
visible, and occasionally, in cases which have ended fatally in my practice, 
severe hemorrhage occurred from the concealed vessels. If the ulcerative 
or gangrenous process extends so deeply into the tissues of the neck that 
hemorrhages occur, death is the common result ; but if the destructive action 
be of moderate extent and other conditions favorable, we may expect recov- 
ery through cicatrization, with perhaps some deformity by contraction of the 
cicatrix. 

When the inflammation of the connective tissue of the neck is extensive, 
involving both the lateral and anterior regions of the neck, the patient is in 
a perilous state. The cellulitis, when extensive and accompanied by much 
swelling, may produce oedema of the glottis, may obstruct respiration by 
compressing the air-passages or the laryngeal nerves, may cause compression 
of the jugular veins, and thus give rise to dangerous cerebral symptoms, or 



292 SCARLET FEVER. 

may lay bare and injure important muscles and nerves, as we have seen. If 
the ulceration or gangrene be extensive, and death do not occur by hemor- 
rhage from arterial or venous twigs, septic poisoning may occur, increasing 
still more the fatal nature of the malady. 

Some cases of this complication are melancholy in the extreme, as 
one related by Cremen, in which ulceration of the pharynx occurred, allow- 
ing the escape of food and preventing deglutition. In severe scarlatinous 
pharyngitis the inflammation sometimes extends along the Eustachian tube, 
causing its occlusion. This accident will be considered when we treat of 
otitis media, another grave complication. It often also extends into the nares, 
causing catarrh of the Schneiderian mucous membrane, with discharge of 
muco-pus from the surface. Not infrequently ulceration or gangrene occurs 
in the faucial surface, producing more or less destruction of tissue and form- 
ing excavations, while the cutaneous surface retains its integrity and is not 
even reddened. The following case shows how grave the complication which 
we are now considering sometimes is when the external surface of the neck 
is not involved, and how the inflammation by extension outward from the 
fauces may involve the middle ear : 

Case 1. — Annie K , aged two and a half years, an inmate of the New 

York Foundling Asylum, was well, except an eczema of the scalp, until the 
night of April 3, 1882, when she was attacked with vomiting and diarrhoea. She 
was feverish and drowsy, and at 2 p. m. on the 4th the scarlatinous efflorescence 
appeared upon her neck, body, and lower extremities; tongue coated; pharynx 
red; temperature (axillary) 103°; pulse 160. The symptoms and aspect indi- 
cated a grave form of the malady, and the usual sustaining treatment was 
ordered. On April 6th the temperature was 102°, pulse 144, tongue less coated, 
eruption fading, less stupor, no albumen in urine. April 6th, morning tempera- 
ture 102°, pulse 160; passed a restless night; stools thin and too frequent; has 
grayish patches in the throat; p.m. temperature 103i°, pulse 150. April 7th, 
the diarrhoea continues, and she has a copious muco-purulent discharge from the 
nostrils ; P. M. temperature 103f, jDulse 160. April 10th, the temperature has 
continued at about 103° ; the patient is very sick, with a constant foul-smelling 
discharge from the nostrils ; breath very offensive ; temperature 103.5°, pulse about 
180. April 12th, general appearance a little better, but the posterior surface of 
the fauces is completely covered by a thick pseudo-membrane; had four loose 
stools last night ; temperature and pulse the same as at last record ; a dark, offen- 
sive, and jagged coating over the fauces, and a dark, foul discharge from the 
nostrils as before : examination of the chest negative. April 14th, is much 
prostrated ; temperature 104.5°, pulse rapid and weak ; respiration noisy ; dimin- 
ished resonance over lower two-thirds of left side of chest ; ulcers upon the 
mouth and tongue ; fauces red and ulcerated. April 17th, pulse 150, tempera- 
ture 100.5° ; general appearance somewhat better, but the diarrhoea continues, 
and patches of a diphtheritic character have appeared upon the lips ; moist 
r§,les in left side of chest. The symptoms continued nearly the same until 
April 23d, when she died. A dull percussion sound and distinct bronchial res- 
piration were observed in the left scapular region during the last davs of her 
life. 

Autopsy nine hours after death by the curator, Dr. W. P. Northrup : Body 
well nourished ; the tissues have a jaundiced hue ; lips sore ; on turning the head 
to one side pus runs from the left ear and dirty muco-pus from the mouth. Brain 
normal ; on opening the petrous portion of the left temporal bone the middle ear 
is found full of pus, which communicated freely with the external ear through a 
perforated membrana tympani ; the Eustachian tube cannot be traced in the 
sloughy tissue, and a passage filled with pus extends from the ear to the fauces ; 
opposite the greater cornua of the hyoid bone are two deep ulcers, each having 
about the diameter of a ten-cent piece, with sloughy and offensive base and sides ; 
the left ulcer communicates by a ragged and wide sinus with a dark and sloughy 
cavity of about four drachms capacity ; this cavity is located in the neck under 
the angle of the jaw, apparently occupying the site of a disintegrated gland, and 



COMPLICATIOXS AND SEQUELS. 293 

it opens upon the surface of the fauces. The surface of the larynx has a dusky, 
dirty appearance, sprinkled with little cheesy-looking spots, and covered by a 
dirty, foul-appearing liquid, as if some of the ichorous pus had escaped into it 
from the neck ; about one and a half inches below the vocal cords there is an 
unmistakable pseudo-membrane ; below this, near the bifurcation, the trachea 
has a bright-red color, as if a pseudo-membrane had been peeled from it, leaving 
the surface raw. The detachment of a pseudo-membrane from this part, if it did 
occur, must have been ante-mortem, for the organ had been carefully handled in 
making the autopsy. Between the apex of the left lung and the median line the 
tissues of the neck, dissected upward, are found indurated, yellow, and giving 
an offensive odor, showing that the cervical cellulitis had extended downward 
farther than usual. The" bronchial glands have undergone hyperplasia, being 
enlarged and hard. The right lung is normal ; about one-half of the left lower 
lobe is consolidated, and when cut is found to be gangrenous and offensive. The 
liver is apparently somewhat enlarged ; spleen normal in size ; gastric mucous 
membrane has a congested appearance and is covered with mucus ; mesenteric 
glands enlarged, pale, and firm ; Peyer's patches swollen and pale; at lower end 
of ileum some pigmentation of these glands ; in large intestine the solitary 
glands are enlarged, and a few of them pigmented ; kidneys pale, cortex thick- 
ened, and markings indistinct. Microscopical examination : In the pia mater 
perhaps a little increase of cells ; meninges of brain otherwise normal. The 
trachea shows well-marked diphtheritic inflammation ; it contains a film of 
pseudo-membrane ; evidences of inflammation occur also upon the laryngeal 
surface, though less marked than in the trachea. The solidified portion of the 
lung exhibits the ordinary lesions of broncho-pneumonia, with some interstitial 
change. In the kidneys we find parenchymatous nephritis, with some cell-growth 
in the Malpighian bodies. 

The above case has been related at length, not only because it shows how 
severe and destructive the inflammation of the throat, extending into the 
tissues of the neck, sometimes is, but because four other complications or 
sequelae were also present — to wit, otitis media, diphtheria, nephritis, and 
pneumonia. We see how formidable a disease scarlet fever sometimes is 
when attended by the inflammations to which it so frequently gives rise, for 
a child older and stronger than this, if thus affected, would inevitably have 
perished with the best possible treatment. 

In localities where diphtheria is endemic, as in Xew York City and Paris, 
scarlet fever is often complicated by pseudo-membranous inflammation of the 
fauces and air-passages. In severe cases the Schneiderian as well as the 
faucial surface is covered with pseudo-membrane, so that it can be readily 
seen on inspecting the anterior nares. Occasionally, this exudation appears 
upon the laryngeal and tracheal surfaces, as in the case which I have related 
above and in others presently to be related, causing dangerous embarrassment 
of respiration. This complication sometimes begins almost at the commence- 
ment of scarlet fever, but in most instances it does not occur before the third 
or fourth day, and it sometimes does not appear till in the declining stage of 
the fever. When it begins it intensifies the fever and produces general 
aggravation of symptoms. 

The elaborate treatise by Sanne of Paris on diphtheria contains a chapter 
entitled " Secondary Diphtheria." In it the author says, what all who are 
familiar with diphtheria will agree to, that secondary diphtheria does not 
differ in nature from the primary form, and that it exhibits a tendency " to 
occupy the organs which are themselves the seat of the more pronounced 

local determinations of the primitive malady Diphtheria is seen in 

the course or sec^uel of numerous diseases. Some appear to have a special 
proclivity for engendering diphtheria ; these are specific maladies : measles, 
scarlet fever, pertussis." Sanne's statistics relating to the seat of scarlatinous 
dinhtheritic exudation are as follows : 



294 SCARLET FEVER. 

Fauces alone attacked 15 cases. 

Fauces with larynx attacked 4 " 

Fauces with nasal fossa attacked 8 " 

Fauces with larynx and nasal fossa attacked 4 " 

Fauces with larynx and bronchi attacked 1 " 

Fauces with nasal fossa and lips attacked 1 " 

Fauces with lips and skin attacked . . 1 ** 

Fauces unaffected 3 " 

Diphtheria generalized 2 '' 

Larynx only afJected 2 " 

Nasal fossa 1 " 

The opinion of so good an observer as Sanne, that when in scarlet fever 
pseudo-membranous exudation appears upon the mucous surfaces which are 
the seat of scarlatinous inflammation, diphtheria has supervened, and not a 
croupous form of scarlatinous phlegmasia, carries with it great weight. 

Nevertheless, one of the most difficult problems which we have to deal 
with in certain cases is to distinguish diphtheritic from non-diphtheritic 
inflammation ; and I see no reason why the scarlatinous inflammation when 
intense may not be sometimes membranous. We know that in some cases 
of dysentery a fibrinous exudation occurs upon the surface of the colon ; 
that in croupous pneumonia fibrin exudes into the bronchioles and alveoli of 
the lungs ; and that physicians in localities where there is no diphtheria meet, 
though at long intervals, cases which they designate croupous pharyngitis 
and laryngitis ; and it seems probable that the intense inflammation of 
anginose scarlatina sometimes produces the same exudation. Moreover, it is 
very difficult to distinguish in the swollen fauces between a membranous 
exudation and ulceration or superficial gangrene so common in malignant 
scarlet fever. The grayish-white surface, jagged and foul, may be the one 
or the other, an exudation or a sphacelus, and in certain instances it is impos- 
sible to discriminate between the two conditions at the bedside. 

Diphtheria complicating scarlet fever occasionally begins nearly simulta- 
neously with the latter. Henoch states that exceptionally he has observed 
suspicious patches upon the fauces before the appearance of tKe scarlatinous 
eruption upon the skin ; and he adds : " I have had repeated opportunities 
of observing this unusual beginning. In such cases we must ask ourselves 
whether the first afi"ection was really connected with the second, or whether 
the former was a true primary diphtheria rapidly followed by scarlatina. 
This opinion is favored by the fact that I had only observed such cases in 
the hospital, in which infection with various forms of contagion can scarcely 
be avoided." 

But usually it is not till the third or fourth day of scarlet fever that this 
complication begins. The patient has been progressing favorably with the 
fever tillon a certain day a marked aggravation of symptoms occurs. A 
higher temperature, more pungent heat, and the physiognomy of a more 
serious malady are present. On inspecting the fauces to discover the cause, 
we observe a pellicle forming upon the tonsils and perhaps other portions of 
the faucial surface. Often the entire aspect of the case changes by the 
occurrence of this complication, a mild case of scarlet fever becoming grave 
and fatal in consequence. Thus in a case which I saw with Dr. Hardy of 
New York the membranous inflammation of diphtheria, commencing upon 
the fauces on the third day of scarlet fever, extended to the Schneiderian 
membrane, and thence along the left lachrymal sac to the eyelids, producing 
redness and swelling along the side of the nose and upon the cheek like that 
of erysipelas. A thick diphtheritic pellicle occurred upon the under surface 
of each eyelid on the. left side, with great tumefaction of both lids, gangrene 
of the cornea, and destruction of the eye. The case soon ended fatally. 



COMPLICATIONS AND SEQUELS. 295 

A pellicular exudation sometimes occurs in the larynx and trachea during 
the course of scarlet fever as a thin film, rendering the respiration noisy, but 
the development of a thick and firm pseudo-membrane, so as to imperil the 
life of the patient from the stenosis in the air-passages, has been much less 
frequent in my practice than it is in primary diphtheria and in diphtheria 
complicating measles or pertussis. The following were cases of this severe 
complication occurring in a recent epidemic in the New York Foundling 
Asylum. In these cases the respiration was noisy, but the obstruction to 
breathing was apparently due to infiltration and swelling around the aper- 
ture of the glottis, more than to the pseudo-membrane which the autopsies 
showed to be present : 

Case 2. — A child aged three and a half years, who previously had symptoms 
of mild catarrhal croup, with moderate redness of the fauces, sickened with scar- 
let fever on Oct. 1, 1882, the rash being profuse and soon covering nearly the 
entire body. The axillary temperature was 103°, pulse 140; slight stridor in 
breathing and some cough ; fauces very red, but free from membrane. Oct. 2d, 
restless, sleeping but little ; has vomited four times. Oct. 3d, temp. 103.5°, pulse 
120; fauces much swollen ; still vomiting ; rash abundant. 4 p. M., temp. 104.3°, 
pulse 128 ; tongue clean; some discharge from nares; urine not albuminous, but 
its quantity diminished. Oct. 4th, aspect that of very severe sickness ; profuse 
discbarge from nostrils ; fauces of a deep-red color, and a pseudo-membrane over 
tonsils and uvula ; tumefaction along the sides of the neck ; temp. 104°, 23ulse 
140 ; breathing moderately stridulous ; urine is passed more freely than yester- 
day ; evening temp. 105°. Oct. 6, croupy symptoms more marked ; tonsils and 
uvula greatly swollen, so that the fauces are almost occluded; temp. 103.5°; 
breathing difiicult, but apparently sufficient oxygen is received ; profuse nasal 
discharge, and other symptoms as before. About 1.30 p. m. he was raised to take 
some milk, and suddenly became asphyxiated. His face was dusky, the eyes 
protruded, and he voided urine and feces. Dr. Swift, who attended the child, 
and to whom I am indebted for this history, immediately performed tracheotomy, 
which gave temporary relief by the expulsion of a considerable quantity of 
pseudo-membrane through the opening. On the following day the respiration 
again became obstructed at some point below the canula, so that it could not be 
removed ; the features grew livid, and death occurred in convulsions twenty-six 
hours after the tracheotomy. 

The autopsy was made by Dr. W. P. Xorthrup, curator of the asylum, who 
found the pharynx covered by a membrane which was traced to the posterior 
nares ; larynx, trachea, and bronchial tubes as far as the third divisions covered 
with membrane ; portions of the tracheal surface denuded, and the mucous mem- 
brane underneath of a bright-red color and smooth. 

Case 3. — Katie, aged six and a third years, was returned to the asylum on 
Nov. 18th. Three days later (Nov. 21st) she had sore throat, reddened fauces, 
coated tongue, and a faint rash upon the neck, chest, and arms; eyes injected; 
temp. 102°. In the afternoon temp. 103° ; eruption still faint. Nov. 22d, temp. 
103.5°; an eruption on chest, abdomen, arms, and legs in patches. Evening 
temp. 104°; voice clear. Nov. 23d, temp. 103.5°; tongue red; fauces deeply 
reddened, but without any visible pseudo-membrane ; the scarlatinous eruption 
has appeared over a considerable part of the surface. On the 24th a pseudo- 
membrane occurred over the tonsils and adjacent faucial surface ; her respira- 
tion became labored, and death took place from dyspnoea at 11 p. m. 

Autopsy. — Naso-pharynx covered by a thick fibro-purulent membrane. 
Larynx contains a well-marked pseudo-membrane, but not continuous. Trachea 
covered by a pseudo-membrane, continuous over most of its surface, but in places 
broken and flaky. Where it is detached the mucous membrane is seen under- 
neath, dusky and deeply injected. At the root of the lungs the pseudo-mem- 
brane can be traced along the tubes about an inch in all directions. Nothing 
noteworthy in the other lesions. 

In another case of scarlet fever, in which death occurred after an illness 
of three weeks and from gradually increasing dyspnoea, it is stated in the 



296 SCARLET FEVER. 

records of the autopsy that the larynx was free from a pseudo-membrane ; 
but a thin film extended over a considerable part of the trachea. 

Coryza frequently commences at or about the time of the pharyngitis. 
The inflammation of the Schneiderian membrane is continuous posteriorly 
with that of the fauces, and is announced by redness and swelling, inability 
to breathe freely through the nostrils, and an irritating ichorous discharge. 
Simple coryza in itself involves little danger, though it is an unpleasant com- 
plication, and in the nursing infant it may interfere with drawing the nipple. 
Diphtheritic coryza, on the other hand, which is frequently present when 
diphtheria complicates scarlet fever, involves danger, since it is apt to cause 
ulcerations, hemorrhages, and septic poisoning. When the local symptoms 
are unusually severe and the discharge abundant, it is probable that inflam- 
mation has in some cases extended to the antrum of Highmore. 

Inflammation of the middle ear is another unpleasant and not infrequent 
complication. The statistics of difl'erent aurists collated by Dr. C. H. May, 
and presented in a paper on scarlatinous otitis read before the Paediatric Sec- 
tion of the New York Academy of Medicine, March 4, 1889, show that about 
5 per cent, of all aural aff"ections result from scarlet fever, and in 10 per cent, 
of the cases of total deafness the loss of hearing is from this disease. It is 
due to extension of the catarrh from the pharynx along the Eustachian tube 
to the tympanum. In a considerable proportion of cases of otitis media this 
tube is occluded by the infiltration and swelling of its mucous membrane, so 
that the muco-pus escapes with difficulty or is retained. Hence severe ear- 
ache, an increase of the febrile movement, and outward bulging of the mem- 
brana tympani occur. Sometimes headache or other cerebral symptoms arise, 
probably from the fact that the meningeal artery, which supplies the meninges, 
is connected by anastomosing branches with the tympanum. In one of the 
cases related above it will be recollected that the ulceration and abscess 
extended from the fauces to the middle ear, the entire Eustachian tube 
having disappeared in the ulcerative process. 

Frequently, the otitis escapes detection, its symptoms being masked or 
obscured by the general disease, until the membrana tympani is perforated 
and otorrhoea begins ; but by careful examination the nature of the complica- 
tion can usually be ascertained before the ear is injured to this extent, for a 
patient too young to speak will often press with the fingers against the painful 
ear or lie with the ear pressed upon the pillow, evidently having an increase 
of sufl'ering if placed in any other position. One old enough to speak and in 
proper mental condition makes known the earache as soon as it occurs. In 
most instances the. scarlet fever has continued some days when the otitis 
begins. The otitis may begin insidiously, but in other instances it begins 
with a chill and a rise of temperature to 104° or 105°. The pain referred to 
the ear may be paroxysmal, and it is usually worse at night. It may radiate 
from the ear, following the branches of the fifth nerve. The patient expe- 
riences pain on pressure upon and around the tragus, and when the inflamma- 
tion extends to the mastoid cells, pressure upon the mastoid process is also 
painful. The otitis may be unilateral, but in a large proportion of cases it 
is bilateral. 

The mucous membrane of the tympanum, red and swollen from inflamma- 
tion, secretes muco-pus abundantly, and this, pent up in the cavity, must 
obtain an exit before relief occurs. It is well if the secretion escape, though 
with difficulty, down the Eustachian tube. The destructive action of the pus 
upon the delicate structure of the ear is often such that within a few days 
irreparable harm is done and more or less deafness results. Relief can occur, 
if the Eustachian tube remain closed, only by perforation of the membrane 
and the discharo-e of the secretions into the external meatus. When this 



COMPLICATIOXS AXD SEQUELS. 297 

takes place the inflammation in the most favorable cases gradually abates, the 
aperture in the drum closes, and the integrity of the auditory apparatus is 
preserved. In severe cases the mastoid cells participating in the inflammation 
become filled with muco-pus and tender to the touch, and often the collateral 
oedema causes tumefaction and narrowing of the external ear, which subside 
with the discharge of pus from the tympanum. 

Unfortunately, there is for many a more melancholy history — a more 
destructive inflammation, involving permanent impairment or total loss of 
hearing. This most frequently takes place in strumous or feeble children. 
All grades of inflammation and destructive action occur in diff'erent cases. 
The perforation in the drum-membrane may be large or the membrane may be 
completely destroyed, and the detached ossicles escape one by one into the 
external meatus, and in a few instances, fortunately rare, this occurs in both 
ears, porducing complete and permanent deafness. In my own practice this 
has never occurred, but I have met one or two adults who were totally deaf 
from this cause. 

The mucous membrane which lines the bony wall of the middle ear has 
the function of the periosteum, and therefore when inflamed and subjected to 
pressure is liable to ulcerate. As in other parts of the skeleton under similar 
conditions, superficial caries or necrosis of the underlying bone is liable to occur. 
The carious or necrotic process may extend to the mastoid cells. An ofiensive 
otorrhoea, continuing for months or years, indicates the persistence of this 
pathological state of the tympanum, which is rendered so obstinate by the 
presence of dead bone. A moment's survey of the anatomical relations of 
the middle ear shows the danger to which these patients are liable. A thin 
bony septum, perforated with blood-vessels, and sometimes containing con- 
genital apertures, separates the tympanum from the cranial cavity above. 
Posteriorly lie the mastoid cells, connected with the tympanum by one large 
and several small apertures. Anteriorly is the commencement of the Eus- 
tachian tube, and in close proximity to the tympanum lies the carotid canal, 
and at one point also the superior petrosal sinus. Yirchow has shown how 
inflammation extending from the ear in otitis media sometimes produces such 
compression of the veins or sinuses by the swelling from the infiltration and 
exudation that the circulation is arrested, and the fibrin contained in the 
blood of these vessels is precipitated, forming thrombi, with the most disas- 
trous efi"ect upon the individual. Pus may also burrow in the interstices of 
the bone, causing great pain, or the pent-up secretions, having no outlet for 
escape, may in time undergo caseous degeneration, producing the conditions 
in which tuberculosis so often originates. 

Death not infrequently occurs in chronic otitis media in another way. 
The otorrhoea, after months or years, suddenly ceases, the child complains of 
constant severe headache and is feverish, and the case ends in coma, preceded 
perhaps by convulsions. ^leningitis has occurred, produced by extension of 
the inflammation through the thin bony septum which divides the tympanum 
from the cranial cavity, and at the autopsy hyperjeraia of the meninges, fibrin, 
pus. perhaps softening of the brain and an abscess, are found in the portion 
of the encephalon adjacent to the tympanum. Therefore, otitis media, though 
it often ends favorably, is in many patients an obstinate, dangerous, and even 
fatal sequel of scarlet fever. 

The complication known as scarlatlnov.s rheumatism is regarded by some 
as a synovitis, but its symptoms, especially its shifting from joint to joint, 
seem to ally it to the rheumatic afl"ections. In some epidemics it is common. 
It usually begins toward the close of the first week or in the second week, 
and its common seat is in the ankle, phalangeal, and wrist joints. It is 
attended by very little swelling in most patients, though the joints are tender 



298 SCARLET FEVER. 

and painful on pressure. It does not seem to retard convalescence materially, 
but it produces suffering and involves danger as regards the heart. It sub- 
sides in a few days with the ordinary treatment of acute rheumatism, and 
even without special treatment, the chief danger being that, as in idiopathic 
rheumatism, endocarditis may arise, with permanent crippling of the valves. 
The following was a case of valvular disease having this origin. It occurred 
in my practice. 

Case 4. — Freddy M , aged four years, sickened with scarlet fever March 

6, 1879. The usual vomiting occurred on the first day, and the temperature was 
104°. The case progressed favorably till March 14th, when he complained of 
pain in both wrists, both ankles, and both knees. On March 17th the general 
condition was good, the urine contained no albumen and apparently few urates, 
but he still had pain in the joints of the upper and lower extremities and in the 
back ; pulse 140, temperature 103° ; breathes with a slight moan ; urates in the 
urine, but no albumen. A distinct mitral regurgitant murmur is now heard for 
the first time. Under the use of salicylate of sodium the pain in the joints soon 
ceased, but the mitral murmur is permanent. 

The following prescription is for a child of five years : 

R. 01. gaultherife, f^j ; 

Sodii salicylat., ^iij ; 

Syrupi, f^ij ; 

Aquse, f^iv. Misce. 

Sig. : Give one teaspoonfuU every four hours in water. 

Of the serous inflammations complicating scarlet fever, pericarditis has 
been, according to Rilliet and Barthez, most frequently observed. In this 
country it is probably more common than is usually supposed, but it is less 
frequently detected than pleuritis, the symptoms of which are more con- 
spicuous. 

The following case, which occurred in my practice, was an example of this 
complication : 

Case 5. — C , girl, aged five years and ten months, sickened with severe 

scarlet fever on April 4th. Was delirious; pulse 158 ; had vomiting and consti- 
pation. April 10th, pulse varies from 124 to 153, no delirium ; a considerable 
quantity of urates in the urine. April 11th, has to-day, for the first time, severe 
pain in the epigastrium, with tenderness and moderate distension. Otherwise 
symptoms favorable, but severe ; pulse 140 ; respiration moderately accelerated 
and vesicular in every part of the chest. From this date the symptoms continued 
about the same till April 14th, when the dyspnoea became more marked and the 
action of the heart rapid and tumultuous. The epigastric pain, distension, and 
tenderness continued; the percussion sound was dull over the lower part of the 
chest ; the dyspnoea became rapidly worse, although the pulse had considerable 
volume; and at 5 P. M. death occurred. At the autopsy about one ounce of tur- 
bid serum, with a soft deposit of fibrin, was found in the pericardium. Each 
pleural cavity contained from six to eight ounces of transparent serum, and both 
lungs were readily inflated, except a little of the posterior portions of both lower 
lobes ; no fibrinous exudation over the lungs. The liver extended four inches 
below the margin of the ribs, and upon its convex surface in the epigastrium, 
corresponding with the seat of the pain, was a rough patch of fibrin about one 
and a half inches in diameter. The bronchial mucous membrane was moderately 
injected, as was also that of the colon, and the kidneys appeared hypersemic. 

Among the serous inflammations which complicate or follow scarlet fever, 
pleuritis is one of the most important. It usually begins in the desquamative 
stage, and is frequently suppurative, on account of the feeble state of the 



COMPLICATIOyS AND SEQUELS. 299 

patient when it commences. It has, in my practice, been tedious, as all 
empyemas are, and it does not differ in its clinical history from the idiopathic 
disease. I have met cases of scarlatinous empyema in which, from opposition 
of the family or for other reasons, thoracentesis was not performed and death 
occurred ; others in which this operation effected a cure ; and one, at least, 
in which the patient recovered by escape of pus through a bronchial tube and 
its expectoration. The pleuritis is seldom latent, or so masked by the symp- 
toms of the general disease that it is liable to be overlooked. On the other 
hand, the cough, embarrassment of respiration, and pain referred to the affected 
side render diagnosis easy. 

Dilatation of the heart is common in grave cases of scarlet fever, such 
cases as are properly termed malignant. It is indicated by a feeble and quick 
pulse. Acute infectious maladies, especially those of a malignant type and 
accompanied by a marked rise in temperature, are very liable to cause paren- 
chymatous degenerations in organs, prominent among which is granulo-fatty 
degeneration of the muscular fibres of the heart. This weakens very much 
the contractile power of the heart. But early in malignant cases, probably 
before the muscular fibres are damaged, the contractile power of the heart is 
feeble from impaired innervation, the result of the general weakness. Hence 
this organ, when weakened by structural change and insufficiently stimulated 
through diminished innervation, may not fully empty itself during the systole, 
and consequently it becomes dilated. Dilatation of the heart and imperfect 
contraction of its auricular and ventricular walls facilitate the formation of 
clots in the cavities of the heart ; and this appears to be the immediate cause 
of death in not a few instances. An ante-mortem clot occurring in an}^ of 
the cavities of the heart necessarily seriously obstructs the circulation, unless 
it be of small size. Hence the dyspnoea, which may occur suddenly, and the 
change of pulse to one of marked feebleness and frequency. Large, firm 
white clots are most frequently found in the right cavities. They interlace 
with the chorda9 tendineae, lie even within the auriculo-ventricular (5pening, 
and send prolongations into the pulmonary artery and the cav^. Associated 
with the white clots are dark, soft clots and fluid blood. The left cavities 
may be contracted and empty, or they may contain dark, soft clots or white 
ante-mortem clots. Clots in the left ventricle are sometimes prolonged into 
the aorta as far as the brachiocephalic branches, while those in the left auricle 
may extend to the pulmonary veins. If dilatation of the heart be so great 
that clots form in its cavities, speedy death is probable. Sometimes a patient 
passes through scarlet fever and appears in a fair way to recover, when he 
succumbs to some exhausting sequel distinct from the heart, and at the 
autopsy the heart is found dilated and containing whitish clots, which are 
probably ante-mortem, and which hastened death by obstructing the circula- 
tion. Under such circumstances this state of the heart is attributable in 
great measure to the complication which has weakened its contractile power. 

The following was a case in point ; it occurred in the New York Found- 
ling Asylum : 

Case 6. — E. A , aged three years, had scarlet fever, beginning March 

23, 1882. The symptoms were favorable at first, but serious complications and 
sequelse occurred, which were fatal. The record of April 18th reads : " Appears 
well nourished, but is auEemic ; has otorrhoea ; no oedema ; skin desquamating ; 
dulness on percussion over upper third of right side of chest, anteriorly and pos- 
teriorly ; mucous rales and rude breathing over same area ; fine rales posteriorly 
over lower part of left side of chest; pulse 160, respiration 68, temp. 101|°." 
April 20th, is feeble and takes nutriment with difficulty; tongue thickly coated; 
pulse 160, respiration 68, temp. 101 f°, April 26th, condition about the same as 
at last record, but he is evidently weaker; the lips are ulcerated and fauces still 



300 SC ABLET FEVER. 

swollen. May 2d, cannot speak distinctly ; a brownish, foul-smelling secretion 
lodges on the spoon used in depressing the tongue ; left side of face swollen. On 
the following night eight convulsions occurred, attended by orthopnoea and 
mucous rales in the chest from pulmonary oedema. Diarrhoea supervened and 
the patient died about midnight. 

Autopsy. — Body moderately wasted and very white; several dark -blue spots on 
scalp and face from hemorrhages underneath. A careful examination showed 
the presence of broncho-pneumonia in each lung, with considerable infiltration 
of the walls of the bronchi and cylin(h'ical dilatation of many of them ; cavities 
of the heart dilated, so that this or^an appears much enlarged, and its shape 
approaches the globular; its apex is rounded or obtuse; transverse diameter of 
the right ventricle, when its walls were open and drawn apart, was three and a 
fourth inches ; that of the left ventricle, three and a quarter inches. Similar meas- 
urements of the heart of another child of about the same age, believed to be normal, 
were about one inch less in each direction. All the cavities contain white firm 
clots along with soft dark clots. Lesions observed in other organs were carefully 
noted, some of which were serious ; but the immediate cause of death appeared 
to be imperfect contraction of the heart and the formation of clots in its cavities. 

There can be little doubt that nephritis in its milder form is much more 
common than was formerly supposed. A few years since little attention was 
given by a large proportion of physicians to the state of the kidneys, and the 
urine was not examined till dropsy made its appearance, which only occurs 
in the more severe forms of nephritis and is a late symptom. It is now 
known that catarrh of the renal tubes frequently occurs in a mild form early 
in scarlet fever, without causing albuminuria, dropsy, or any notable symp- 
tom. It may produce a smoky color of the urine, and the appearance in it 
of granular epithelial cells, with an increase of mucus, but no albumen. 
With careful treatment and no exposure to cold the renal catarrh abates 
with the decline of the scarlet fever. It is scarcely severe enough to merit 
the name desquamative, tubal, or parenchymatous nephritis, though it is a 
mild form of the same pathological state. Steiner says, as the result of 
many careful examinations of cases, that hypersemia of the kidneys was always 
present in those who died early in scarlet fever, and that in a certain propor- 
tion of these eases catarrh of the renal tubules was present in addition to the 
congestion. Even in some who died on the second or third day he found 
cloudiness of the epithelium in the renal tubes, although the urine had not 
indicated such a change. The opinion has even been expressed that catarrh 
of the renal tubes is as common in scarlet fever as that of the bronchial 
tubes in measles ; that is, it is a uniform element in the disease ; but this 
appears to be an exaggerated statement, for others have failed to find any 
evidence of renal catarrh in certain cases. 

The nephritis which gives rise to symptoms, and therefore interests the 
practitioner, commonly begins in the declining period of scarlet fever or dur- 
ing the desquamative stage, and is in many instances plainly attributable to 
exposure to cold or to currents of air. It originates either during this period, 
or, if it have previously existed as a mild renal catarrh, it now becomes aggra- 
vated. Dropsy, which always attracts attention, does not occur till the nephri- 
tis has continued for some time. 

Why nephritis, with the subsequent dropsy, so frequently occurs after 
scarlet fever is not fully understood. Rilliet and Barthez attribute it to dis- 
turbance of the function of the skin. The fact has long been observed that 
the kidneys become affected nearly if not quite as frequently after mild as 
severe cases. Indeed, the chief danger in mild cases, when the patients are 
but a short time in bed and are soon allowed to go about, is from the nephri- 
tis. Chilling the surface and checking cutaneous transpiration appear to be 
the immediate cause of this inflammation in a considerable proportion of 



COMPLICATIONS AND SEQUELS. 301 

cases. Therefore, severe attacks of scarlet fever with abundant rash and des- 
quamation, which require the patient to be kept in bed the proper time and 
in a warm room two or three weeks, appear to be less frequently followed by 
this renal disease than are milder cases which are more carelessly treated. 

The most thorough and minute microscopic examinations of the state of 
the kidneys in scarlet fever which have come to my notice were those of E. 
Klein, published in the Loud. Path. Soc. Trans, and illustrated by micro- 
scopic drawings. It appears from these examinations that the changes in the 
kidneys are complex, among which we recognize both those of parenchyma- 
tous or desquamative nephritis and interstitial nephritis ; but we would infer 
that the interstitial nephritis is mild in degree and quite subordinate, or else 
confined to portions of the organ, from the fact that so many permanently 
and fully recover. -The following is a resume of Klein's examinations in 
twenty-three cases. We conclude from these microscopic researches that the 
anatomical changes of both parenchymatous and interstitial nephritis are 
commonly present in greater or less degree in cases of scarlet fever. If 
they are mild or confined to portions of the kidneys, no symptoms occur ; 
but if they are sufiicient in extent or degree to impair the function of these 
organs, then symptoms, as albuminuria, diminution of urine, etc., appear. 

1. Parenchymatous Nephritis^ Proliferation of Nuclei^ Hyaline Degenera- 
tion of Arierioh'S. — The Glomerulo-nepl iritis of Klehs. — Klein found increase 
of nuclei (probably epithelial) in the glomeruli, and hyaline degeneration 
of the intima of minute arteries, especially marked in the afferent arte- 
rioles of the Malpighian bodies. The intima of these vessels was in places 
so swollen as to resemble cylindrical or spindle-shaped hyaline masses, and 
cause narrowing of the lumina of the vessels in which this degeneration 
occurred. Klein observed in some specimens so great hyaline degeneration 
of the capillaries of the Malpighian bodies that circulation through them was 
obstructed. In the more advanced or protracted cases this hyaline substance 
in the glomeruli began to assume a fibrous appearance. Bowman's capsule 
was considerably thickened. This hyaline degeneration of the Malpighian 
bodies Klein discovered in the earliest cases which fell under his obser- 
vation. 

Also in the earliest cases the multiplication or germination of the nuclei 
of the muscular coat of the arterioles was observed, with a corresponding 
increase in the thickness of the walls of these vessels. This change in the 
muscular element was found in the arterioles in different parts of the kidney, 
but it was most conspicuous in these vessels at their point of entrance into 
the Malpighian bodies ; and it was distinctly noticed in other arterioles, both 
in the cortex and in the base of the pyramids. 

In the glandular portion of the kidneys other anatomical alterations were 
observed, indicating parenchymatous nephritis. There were swelling of the 
epithelial lining of the convoluted tubes ; multiplication of nuclei of epithe- 
lial cells, especially in ascending tubules, which lay close to the afferent arte- 
rioles of Malpighian corpuscles ; granular matter, and even blood, in the 
cavity of Bowman's capsule and in the convoluted tubes ; cloudy swelling 
and granular disintegration of epithelium in some parts of the convoluted 
tubes ; detachment of epithelium from the membrane of larger ducts of the 
pyramids in some cases. These parenchymatous changes are already known 
to the profession through the observations and writings of Dickinson, Fen- 
wick, Johnson, Simon, and others. 

Klein, in commenting on the hyaline degeneration which he observed, 
states that Neelsen found the walls of the capillaries of the pia mater thick- 
ened, highly refractive, and of a lardaceous appearance in certain acute infec- 
tious maladies, as variola, typhoid fever, measles, and in one case scarlet 



302 SCARLET FEVER. 

fever.^ Usually, only a small portion of the capillaries were thus affected, 
most frequently at the point of division into branchlets. In a few instances 
Neelsen noticed degeneration of arterioles extending a considerable distance, 
with fusion of the intima, media, and adventitia, and chemical examination 
showed that the substance produced by this degeneration had similar proper- 
ties to elastic tissue. Although the examinations by Neelsen relate to the 
pia mater, two of his observations are especially interesting : first, that the 
hyaline change affects chiefly vessels near their point of branching ; and, 
secondly, that the hyaline substance is of the nature of elastic tissue, for in 
the kidney in scarlatinous nephritis the arterioles undergo the change in 
question chiefly near their point of branching into the capillaries of the 
glomerulus ; and the intima being the part which undergoes the hyaline 
change, it is probable, in the opinion of Klein, that the same substance is 
produced by the degeneration in walls of the vessels of the kidney which 
Neelsen observed in the pia mater, and therefore that it is of the nature of 
elastic tissue. 

This hyaline degeneration of the arterioles is also very marked in the 
spleen in scarlet fever ; and in studying the minute anatomy of the intestines 
and spleen in typhoid fever Klein has found the same degeneration of the 
intima of the minute vessels. He believes that this hyaline change and the 
proliferation of muscle-nuclei which thus occur at an early period in scarlet 
fever in the renal vessels when the kidneys become affected are due to an 
irritating cause acting similarly to that in typhoid fever. 

Klein calls attention to the interesting examinations of the scarlatinous 
kidney made by Klebs, who attributed the diminished urination and the 
uraemic poisoning in certain cases in which the kidneys do not exhibit any 
marked change to the naked eye to what he designates glomerulo-nephritis. 
Klebs says : " In the post-mortem examination the kidneys are found slightly 
or not at all enlarged, firm, .... the parenchyma very hyperaemic. Only 
the glomeruli appear, on close inspection, pale like small white dots. The 
urinary tubes are often not changed at all. Occasionally the convoluted 
tubes are slightly cloudy. The microscopic examination shows that there 
are neither interstitial changes nor proliferation of epithelium, the so-called 
renal catarrh generally supposed to be present in these conditions on account 
of the absence of other perceptible derangements ; and there seems, there- 
fore, leaving out the glomeruli, the congestion of the kidneys alone to remain 
to account for the symptoms during life." But that mere congestion is 
insufiicient to produce the symptoms appears from the fact that it does not 
cause them under other circumstances. Klebs finds, " on microscopic exam- 
ination of the glomerulus, the whole space of the capsule filled with small 
somewhat angular nuclei, imbedded in a finely granular mass. The vessels 
of the glomerulus are almost completely covered by nuclear masses." 

Klein, commenting on these examinations by Klebs, states that in all 
early cases which he examined he observed great abundance of nuclei of the 
glomeruli, but a condition like that described and figured by Klebs ^ he has 
seen in only a few glomeruli ; for a general state of these bodies, as described 
by this observer, and such an excessive proliferation of the nuclei that the 
blood-vessels are completely compressed, was not seen in one of the twenty- 
three cases. Klein therefore questions whether the diminished urination and 
retention of urea in scarlet fever, when the kidneys do not exhibit any con- 
spicuous catarrhal or other change, is due, unless in exceptional instances, to 
compression of the vessels of the glomeruli by nuclear germination, but 
believes, rather, that the obstructed circulation, and consequent diminished 
urinary excretion, are largely due to the changed state of the arterioles. 

^ Archiv der Heilkunde, 1876. ^ Handbueh der Pathol., p. 646, fig. 72. 



COMPLICATIONS AND SEQUELS. 303 

Klein adds that perhaps undue contraction of the arterioles, through stinlu- 
lation by the blood-irritant, may also be a factor in causing arrest of cir- 
culation in the Malpighian corpuscles. As regards cases that perished 
early, he found the parenchymatous change slight, so that a careful ex- 
amination was required in order to detect cloudy swelling and granular 
degeneration. 

2. Interstitial Nephritis. — A second set of changes Klein observed in 
cases that died about the ninth or tenth day. In such cases he found 
changes due to interstitial, in addition to those produced by parenchymatous, 
nephritis. Round cells, lymphoid cells, or whatever else they should be 
called, were seen in the connective tissue of the kidneys. In the kidneys 
of those that died at the end of the first week after the commencement of 
nephritis infiltration with round cells was observed in the connective tissue 
around the large vascular trunks. At a later stage this infiltration had 
extended into the bases of the pyramids and into the cortex. The gradual 
increase in extent and intensity of this infiltration was so decided in the 
cases which Klein observed that he has no hesitation in concluding that 
when interstitial nephritis occurs it begins about the end of the first week, 
in the manner already stated — to wit, as a slight infiltration of the tissues 
around the large vascular trunks, and gradually extends, so that portions 
of the cortex, and rarely portions of the base of the pyramids, are changed 
into firm, pale, round-cell tissue in which the original tubes of the cortex 
become lost. 

The infiltration of the cortex w4th round cells, beginning at the roots of 
the interlobular vessels, spreads rapidly toward the capsule of the kidney, 
and laterally among the convoluted tubes around the Malpighian bodies. . . 
. . In the course of this process considerable parts of the peripheral cortex, 
occasionally of a cuneiform shape, with the base nearest the capsule of the 
kidney, become changed into whitish, firm, bloodless, cellular masses, in 
which Malpighian corpuscles and urinary tubes are only imperfectly recog- 
nized, being more or less degenerated. In some cases attended by this infil- 
tration of the cortex Klein observed a more or less dense reticulation of 
fibres, especially around the interlobular arteries, containing in its meshes 
lymph-cells, chiefly uninuclear. 

In a child of five years that died after a sickness of thirteen days Klein 
found evidence of intense interstitial inflammation, and also emboli, consist- 
ing of fibrin with a few cells, in the arteries, both in those of large size 
and in the arterioles, chiefly where they enter the Malpighian corpuscles. 
He states that in the specimens which he examined the more intense the 
degree of interstitial change, the greater was the enlargement of the kid- 
neys, and the more distinct also were the evidences of parenchymatous 
nephritis in the urinary tubes, which either contained casts or were in pro- 
cess of destruction. By being crowded with inflammatory products, espe- 
cially cells, the Malpighian corpuscles were obliterated, undergoing fibrous 
degeneration. A very curious fact observed was the deposit of lime in the 
urinary tubes, first of the cortex, and then also of the pyramids, at an early 
stage of scarlet fever, when the kidneys otherwise showed only slight change. 
Several observers, as Biermer, Coats, and Wagner, have each described a case 
of scarlet fever with interstitial nephritis, which they consider unusual ; but 
Klein has apparently demonstrated, as we have seen, by a large number of 
microscopic examinations, that this form of nephritis is common after the 
ninth or tenth day. 

Nephritis, in proportion to its extent and gravity, is accompanied by 
languor, febrile movement, thirst, loss of appetite and strength. At first the 
patient experiences but slight pain in the head or elsewhere, and the quan- 



304 SCARLET FEVER. 

tity of urine is not notably diminished ; but as the disease continues urination 
becomes less frequent and the urine more scanty. Albuminuria occurs, while 
the urea is only partially excreted, and therefore it accumulates in the blood. 
If the nephritis be so severe or protracted that this principle accumulates to 
a certain extent, grave symptoms occur, as headache, vomiting, apathy or 
restlessness, and, more dangerous than all, eclampsia, which is not unusual 
in these cases. Microscopic examination of the urine shows the presence in 
this liquid of blood-corpuscles, granular epithelial cells, and hyaline or granular 
casts or both. The specific gravity of the urine is diminished. But a 
large quantity of albumen in the urine may render the specific gravity as 
high or higher than in health. 

The "altered state of the blood soon gives rise to transudation of serum, 
first observed in most cases as an anasarca occurring in the feet and ankles. 
The oedema, if not checked by treatment or through mildness of the disease, 
extends over the limbs, scrotum, and sometimes upon the trunk. It is well 
if the dropsy remain limited to the subcutaneous connective tissue, but, 
unfortunately, it is apt to occur, if the nephritis continue, in and around the 
internal organs, producing, mentioned in the order of frequency, pulmonary 
oedema, eff"usion into the pleural and peritoneal cavities, the pericardium, the 
encephalon, and lastly into the connective tissue of the larynx, causing that 
very fatal complication, oedema of the glottis. Although this is the common 
order in which dropsies occur, exceptions are not infrequent. Even the ana- 
sarca may not be the first to appear, although in the vast majority of cases 
it has the precedence. Thus, Rilliet relates the case of a boy of five years 
who twenty days after the occurrence of scarlet fever, and six hours after 
the appearance of bloody and albuminous urine, had double hydrothorax, 
rapidly developed. As long as the hydrothorax continued no anasarca was 
observed, but as it declined anasarca appeared. Legendre cites a case in 
which oedema of the lungs occurred without anasarca or other dropsy. 
Occasionally, the anasarca and internal dropsies take place nearly simulta- 
neously. The nephritis and consequent serous effusions usually appear 
within three weeks after scarlet fever ends, but cases occur in which the 
effusions are first observed as late as the fourth and fifth weeks. The patient 
may be considered to possess immunity from this sequel if he have reached 
the close of the fifth week after the abatement of scarlet fever without its 
occurrence. 

The dropsy is usually acute, but it may assume the chronic form, since 
the nephritis which causes it, happily curable in most instances, may, if 
neglected, become chronic. Whether the dropsy in itself involve danger 
depends in great part on its location. Anasarca and ascites may exist a long 
time with little suffering or danger, but a small amount of serum in certain 
other localities causes alarming symptoms and speedy death, ffidema of the 
lungs, hydro-pericardium, oedema of the glottis, and intracranial effusions 
are always dangerous, and the last two are sometimes fatal within twenty- 
four to forty-eight hours. Oedema of the lungs has been fatal within 
twelve hours from the appearance of the first symptoms of obstructed respi- 
ration. 

Cerebral symptoms occurring during scarlatinous nephritis are probably 
sometimes due to the irritating effect of the retained urea on the nervous 
centre. In other cases the cause appears to be cerebral oedema or compres- 
sion of the brain by effusion of serum within the ventricles and upon the 
surface of the brain. Headache, dull or severe, dilatation of the pupils or 
their oscillation in a uniform light, vomiting with little apparent nausea, are 
common symptoms of scarlatinous nephritis when it has continued a few days, 
and the excretion of urea is so diminished that this substance begins to exert 



ANATOMICAL CHARACTERS. 305 

its poisonous effect on the sj'stem. Sucli symptoms are frequently followed 
by somnolence threatening coma or by eclampsia, unless the patients are 
promptly and properly treated. In some patients that die of scarlatinous 
nephritis, death occurring in convulsions or coma, no appreciable lesions are 
observed within the cranium, unless more or less congestion, the fatal ending 
being attributable to the uraemia. In other instances we find an effusion of 
serum within the ventricles or upon the surface of the brain. Although the 
symptoms in scarlatinous nephritis and urasmia may appear very unfavorable, 
the prognosis is usualh' good under prompt and appropriate treatment. Thus 
severe convulsions and a degree of somnolence that bordered on coma may 
abate, and convalescence be fully established within a few days. Rilliet and 
Barthez announce ten recoveries in thirteen patients affected with convulsions 
due to this renal affection. 

Anatomical Characters. — Scarlet fever being, as we have seen, a con- 
stitutional febrile disease of an ataxic nature, and accompanied by certain 
inflammations, necessarily affects the composition of the blood ; but since this 
disease varies so greatly in type or severity, the state and appearance of this 
liquid also vary. At the autopsies of the more malignant cases we find the 
blood dark and fluid, with small, soft, and dark clots in the heart and large 
vessels. In other cases the clots are large, firm, and solid, as described in a 
preceding page. In malignant cases that end fatally Rilliet and Barthez 
state that both the large and small vessels of the cerebral meninges and the 
brain are found hypertemic, but in a variable degree. In those who die in 
coma, preceded by delirium or convulsions, during the eruptive stage the 
intracranial congestion is usually marked, with perhaps some transudation 
of serum, but without inflammatory lesions. The fibrin in scarlet fever 
remains in about normal proportion, except as it is increased by inflamma- 
tory complications. Andral found an increase in the proportion of blood- 
corpuscles from 127 to 136 parts in 1000. 

The respiratory apparatus, except the 8chneiderian membrane, is usually 
normal when no complications exist. Samuel Fen wick ^ made post-mortem 
examinations in sixteen cases of scarlet fever, and concludes from them that 
inflammation of the mucous membrane of the stomach and intestines occurs 
like that of the skin, followed by desquamation of the epithelial cells, like 
that of the epidermis. I have had the opportunity of examining the stom- 
ach and intestines of those who died of scarlet fever in the eruptive stage, 
and have not found any unusual hyperaemia of the gastro-intestinal surface, 
except when gastro-intestinal inflammation, usually indicated by diarrhoea, 
had occurred as a complication. 

In some cases the abdominal organs exhibit changes which suggest a 
resemblance to typhoid fever. The spleen is enlarged and somewhat soft- 
ened, and Peyer's patches and the solitary glands are thickened and promi- 
nent, but less in degree than in typhoid fever. The mesenteric glands also 
are in a state of hyperplasia. In other patients these parts appear 
normal. 

Klein made microscopic examination of the liver in eight cases, and states 
that he found granular opaque swelling of liver-cells, and changes in the 
internal and middle coats of certain arteries similar to those observed in the 
kidneys which have been described above. He also found evidences of inter- 
stitial inflammation, as an increase of round cells and connective tissue in the 
liver. He remarks also that he observed hyaline degeneration of the intima 
of arteries in the spleen. Rilliet and Barthez state that swelling and soften- 
ing of the spleen are exceptional in scarlet fever, but are sufficiently common 
to merit attention. In post-mortem examinations which I have witnessed 

^ London Lancet, Julv 23, 1864. 
20 



306 SCARLET FEVER. 

nothing noteworthy has appeared to the naked eye in the state of the liver, 
nor ordinarily in that of the spleen. 

The efflorescence, though one of the anatomical characters, has perhaps 
been sufficiently described in the foregoing pages. It begins over the neck, 
chest, and groins as numerous reddish points not larger than a pin's head, 
closely crowded together, but with skin of normal color between. It is esti- 
mated that the aggregate efflorescence and aggregate normal skin over a given 
area are about equal. If the cutaneous circulation be active and the rise 
of temperature considerable, these spots extend and coalesce, producing an 
efflorescence like erythema or like the hue of a boiled lobster, to which it 
has been likened. The efflorescence, less upon the face than upon the trunk, 
contrasts in this respect with that of measles, in which the rash is full in the 
face, often causing some swelling of the features. It is also less upon the 
palmar and plantar surfaces than elsewhere. It scarcely causes any percep- 
tible elevation of the skin, but in certain localities, as upon the backs of the 
hands and upon the forearms, it communicates the sensation of slight rough- 
ness. The seat of the efflorescence is mainly in the superficial layers of the 
skin, but it is said that it sometimes has occurred upon a cicatrix, as that 
from a burn. In the robust and in favorable cases in which the circulation 
is active the rash has a scarlet hue, and when the cutaneous capillaries are 
emptied and the skin rendered pale by pressure with the fingers, the circula- 
tion immediately returns when the pressure is removed. In malignant cases 
the color is not scarlet, but dusky red, and so sluggish is the capillary circula- 
tion that the skin when pressed upon recovers the blood very slowly. In 
grave cases also extravasation of blood in minute points or transudation of its 
coloring matter sometimes occurs in portions of the surface when, of course, 
decolorization is not fully produced by pressure. In cases ending fatally, 
during the eruptive stage the efflorescence may entirely disappear in the 
cadaver, or it remains upon parts of the surface, especially depending por- 
tions. Desquamation is attributable to the exaggerated proliferation of the 
epidermis and the loosening of its attachment by the inflammation. 

Diagnosis. — In the commencement of scarlet fever, prior to the eruption, 
no symptoms or appearances exist which enable us to make a positive diag- 
nosis. Positive statement in reference to the nature of the attack should be 
deferred, for the credit of the physician. Still, if a child with no appreciable 
local disease sufficient to cause the symptoms a few days after exposure to 
scarlet fever, or during an epidemic of this malady, be suddenly seized with 
fever, the pulse rising to 110, 120, or more, and the temperature to 102°, 
103°, or 105°, scarlatina should be suspected. The diagnosis is rendered more 
certain at this early stage if vomiting occur, and especially if the fauces be 
red, for hyperaemia of the fauces, due to commencing pharyngitis, is one of 
the earliest and most constant of the local manifestations of scarlatina. 

When the eruption has appeared the nature of the malady is in most 
instances apparent. The punctate character of the eruption before it 
becomes confluent, its occurrence within twenty-four hours after the fever 
begins over almost the entire surface, but its absence or scantiness upon the 
face, and especially around the mouth, serve to distinguish it from other 
diseases. 

Scarlet fever and measles were long considered identical by the profes- 
sion, and, though the ordinary forms of these maladies can be readily distin- 
guished from each other, cases occur in which the differential diagnosis is 
attended by some difficulty. But there are differences in the symptoms and 
course of the two diseases which aid in discriminating one from the other. 
Measles begins with marked catarrhal symptoms, as if from a severe cold. 
Mild conjunctivitis, causing weak and watery eyes, coryza, and mild laryngo- 



DIAGNOSIS. 307 

bronchitis, with accompanying cough, precede the eruption three or four 
days and continue during the eruptive stage. The fever during the first 
or initial stage of measles is remittent, the evening temperature being two 
or three degrees higher than that in the morning. Contrast this with the inva- 
sion of scarlet fever, in which the only catarrh is that of the buccal and faucial 
surfaces, and there is consequently little or no cough, and the rise in tem- 
perature, ordinarily high in the beginning, is nearly uniform in the different 
hours of the day. The scarlatinous eruption appears, as we have seen, within 
twelve to twenty-four hours about the neck and upper part of the chest, and 
spreads over the body in a shorter time than that of measles, which appears 
on the third day. The rash of measles begins to fade at the close of the 
third or in the fourth day after its appearance, that of scarlet fever not till 
from the sixth to the eighth day. In nearl}* all cases of measles, even when 
the rash is confluent upon the face and a considerable part of the trunk in 
consequence of the high fever and active cutaneous circulation, we observe 
the characteristic rubeolar eruption upon certain parts of the surface, as the 
extremities ; which, in connection with the history, renders diagnosis certain. 

Erythema resembles the scarlatinous eruption, but its duration is com- 
monly shorter. It is limited to a part of the surface, and it is accompanied 
by much less fever. The temperature in erythema does not usually rise 
above 100°. unless for a few hours, whereas in scarlet fever it continues 
several days considerably above 100°. The scarlatinous efflorescence has 
also a brighter red or more scarlet hue than that of erythema, except in the 
more malignant cases, in which the severity of the symptoms renders the 
diagnosis clear. But an important aid in differentiating the one from the 
other of these diseases is the fact that in erythema there is, with few excep- 
tions, no faucial inflammation, and in the few instances in which it is present 
it is slight and transient, fading within a day or two. 

Scarlet fever is readily diagnosticated from diphtheria, although the 
affinity is close between these two maladies. The early appearance of the 
pseudo-membrane upon the fauces in diphtheria, its absence in scarlet fever, 
and the absence of any appearance resembling it until the fever has continued 
some days, and the characteristic efflorescence upon the skin in scarlet fever, 
render diagnosis easy. If scarlet fever have continued some days when 
first seen by the physician, the diphtheritic pseudo-membrane may be present 
as a complication, or the fauces may present an appearance like diphtheria 
from ulceration or sloughing and the presence of foul and offensive secretions, 
which produce a dark -grayish and fetid mass over the faucial surface. Under 
such circumstances the character of the disease is ascertained by the history 
of the case, and especially by the occurrence of the scarlatinous eruption. 
An erythema transient and limited to a part of the surface sometimes appears 
in the commencement of diphtheria, and at a later period, as a result of the 
toxaemia upon the extremities. Roseoloid points and patches often occur 
upon the extremities. Both kinds of rash can be readily diagnosticated from 
that of scarlet fever, for the erythema, as has been stated, is transient and 
partial, and does not exhibit minute points of deeper injection, while the 
toxemic rash differs in form and aspect from that of scarlet fever, and appears 
at a stage when the scarlatinous efflorescence has faded or begun to fade. 

The efflorescence of rotheln sometimes closely resembles that of scarlet 
fever, though it is usually more like that of measles ; but it is ordinarily 
accompanied by symptoms which are much milder than those of scarlet fever, 
and it begins to abate as early as the third, and disappears on the fourth, 
day. The eyes have a suffused appearance, the temperature may reach 102° 
or 103°, and the efflorescence may be as general over the body as that of 
scarlet fever, but there is not the aspect of serious indisposition, and the 



308 



SCARLET FEVER. 



speedy abatement of the symptoms shows that the disease is not scarlet 
fever. 

Prognosis. — The prognosis depends on the form of scarlet fever, whether 
mild or severe, the strength of the patient, and the presence or absence of 
complications or sequels. The type of the disease is sometimes so mild 
throughout an epidemic or during a series of years that death seldom occurs, 
whatever the mode of treatment ; but afterward the type changes, and the 
percentage of deaths increases and remains high till another amelioration in 
the type occurs. 

Sydenham in the middle of the seventeenth century stated that scarlet 
fever, as he saw it in London, was so mild that it scarcely deserved the name 
of disease : " Vix nomen morbi merebatur." Morton some years later, and 
Huxham in the following century, had abundant reason to regret the change 
of type, and now throughout Great Britain scarlet fever is one of the most 
fatal and most dreaded of the diseases of childhood. In Dublin during the 
present century, prior to 1834, scarlet fever was uniformly mild, so that on 
one occasion of eighty patients in an institution all recovered. In 1834 the 
type of the disease totally changed and epidemics of unusual virulence 
occurred. The type frequently changes from mild to severe or severe to 
mild, not only in consecutive years, but in consecutive months. A few years 
since a distinguished physician of New York treated about fifty cases of 
scarlet fever in one of the institutions without a single death, but a few 
months later the type of the malady changed, and his own son was among 
those who perished from it. The prevailing type of the disease should there- 
fore be considered in giving the prognosis when in the commencement of a 
case we are asked the probability as regards the termination. 

Extensive statistics, including those collected by Murchison from various 
sources, show that in different, epidemics the mortality may vary as much as 
from 3 per cent. (Eulenberg of Coblentz) to 19.3 per cent, (cases seen by 
myself in New York City in 1881-82, many of which were complicated by 
diphtheria), or even to 34 per cent, (epidemic in the Palatinate in 1868-69). 
The hospital statistics of Rilliet and Barthez gave 46 deaths in 87 cases, or 
about 53 per cent. 

Observations have thus far failed to establish any connection in the 
atmospheric conditions of temperature or moisture and the type of scarlet 
fever. G-rave as well as mild epidemics have occurred in all climates and 
seasons. 

The mortality is nearly equal in the two sexes, but age has a marked 
influence on the percentage of deaths. The period of the greatest mortality, 
and also of the greatest frequency, of scarlet fever is between the ages of 
one and six years. The following are statistics bearing on the relation of the 
age to the percentage of deaths ; 



From the close From the 5th to 
Under 1 year, of Ist till close the 12th 

of 5th year. year. 



Fleishman : 


; Cases 
Deaths . 


8 
6 


204 

88 


260 
51 




Kraus : 


Cases 
Deaths 


13 

4 


1st to close of 
6t.h year. 

113 

29 


6th to 12th 
year. 

106 

10 

7th to 16th year-. 


From the 12th 
to 20th year. 

40 

2 


Voit: 


Cases 
Deaths . 


5 

1 


166 
24 


109 
10 





PROGNOSIS. 309 

Under 1 year, ^^n 1st U,^close ^,^^ ^ y,,,, 

Roset: Cases . 43 156 88 

Deaths .16 31 3 

Under 5 j'ears. 5th to 10th year. 10th to loth year. Over 15 years. 
Russinger: Cases . 101 126 47 27 

Deaths .21 20 3 

These statistics, which I believe correspond with the observations of others, 
show that although few cases occur in the first year, the percentage of deaths 
is large, and that a majority of the total deaths from this malady occur under 
the age of six years. After the sixth year the greater the age the less the 
proportionate number of deaths. 

Scarlet fever is liable to so many complications and sequelas that a physi- 
cian should not predict a certain favorable termination in the beginning, how- 
ever mild and regular the symptoms may be. But a favorable result may 
be expected if the attack be mild, the efflorescence appear at the proper time 
and extend over the entire surface, the angina be moderate and accompanied 
by little or no cellulitis or adenitis, with pulse under 140, temperature not 
above 103°, and no marked nervous symptoms. 

Whether the complications or sequelte be dangerous depends upon their 
character. Rheumatism has never in my practice been dangerous, nor has it 
materially retarded convalescence, except when it affected the heart, causing 
pericarditis or endocarditis, when it involves great danger. Nephritis, if it 
be moderate, attended b}' little albuminuria and serous effusion and by the 
occurrence of few renal casts in the urine, commonly ends favorably under 
judicious treatment, as we have already stated ; but severe nephritis, with 
abundant albuminuria and casts and serous effusions, soon gives rise to alarm- 
ing symptoms, and is the cause of death in a considerable number of instances. 
A similar remark is applicable to the angina, which occurs in all grades of 
severity. If it be attended by much cellulitis, with considerable ulceration 
or necrosis, the state is one of danger in consequence of the difficulty in 
administering sufficient nutriment, as well as from the diminished assimilation 
and the loss of strength due to the prolonged inflammatory fever, the septic 
poisoning, and the occasional hemorrhages. Complication by pharyngeal or 
nasal diphtheria, now so common where diphtheria is endemic, also greatly 
increases the danger. 

Many cases, even when their course is normal and without complications, 
involve danger, and some are necessarily fatal, from the direct effect of scar- 
latinous blood-poisoning. Such are grave or malignant forms of the disease 
which the experienced eye recognizes at a glance. Death often occurs rap- 
idly from the toxemia. Such cases are characterized by high temperature 
(105° or 106°), rapid pulse, dusky-red hue of the surface from languid 
capillary circulation, pungent heat, frequent vomiting, diarrhoeal stools, a dry- 
brown tongue, and marked nervous symptoms, such as delirium, great rest- 
lessness, or stupor. Not a few in this form of scarlet fever take eclampsia, 
which is likely to be severe and repeated, and to end in fatal coma. 

Other inflammatory complications and sequels, which have been described 
in the preceding pages, retard convalescence and jeopardize the life of the 
patient, such as empyema, endocarditis, pericarditis, and pneumonia. Otitis 
media is seldom immediately dangerous, although it may be painful and 
involve serious consequences, even a fatal meningitis, as has been stated 
above, after months or years of otorrhoea. Anomalous cases are believed to 
be, as a rule, more dangerous than such as are attended by an early and full 
efflorescence and have the usual symptoms. 



310 SCARLET FEVER. 

Treatment. — Proph^Iaxi>;. — Since the discovery by Jenner of the pro- 
phylactic power of vaccination as regards smallpox, the attention of the pro- 
fession has been frequently directed to the prevention of scarlet fever. Bel- 
ladonna has been employed for this purpose by a class of practitioners who 
believe in the theory that an agent which produces symptoms similar to those 
of a disease is antagonistic to that disease, and therefore tends to prevent it, 
or, if it be present, to render it milder ; and since this herb causes an efflo- 
rescence upon the skin and redness of the fauces, it Avas selected as the 
proper preventive and remedial agent for scarlet fever. Its, use, however, 
for this purpose has been fruitless, and it is now nearly or quite discarded. 

It is now known, from a considerable number of observations, that scarlet 
fever occasionally occurs in the domestic animals during epidemics of the 
disease in children. It is stated that Spinola observed it in the horse ; that 
Heim saw a dog that occupied the same bed with a scarlatinous patient sicken 
with fever, which was followed by desquamation ; that Letheby saw scarla- 
tina in swine, and Kraus in young cattle. Prominent veterinary surgeons, as 
Williams of Great Britain, admit the occurrence of scarlatina in animals, and 
the hope has arisen that since smallpox is modified in cattle so as to afford us 
the vaccine virus, perhaps scarlet fever may also be modified by passing 
through one of the lower animals, so that a milder and less fatal form of the 
disease might be produced in man by inoculation from the animal. This 
theory, though it deserves investigation, is far from being established. It 
has not yet, so far as I am aware, been shown that scarlet fever is milder in 
any animal than in man, nor, if we admit that it is modified in the animal, is 
it certain that the disease could be returned to man in the modified form. 
In the A^eiv York Medical Record for March 24, 1883, some experiments are 
detailed by S. W. Strieker of Orange, New Jersey. He cites experiments of 
Caze and Feltz, who injected scarlatinal blood under the skin of 66 rabbits, 
and of these 62 died wnthin eighteen hours to fourteen days, which indicated 
a highly poisonous state of the blood employed, either septic or scarlatinous, 
and certainly no mitigation of the virulence of the scarlet fever. Strickler 
obtained from Williams of Edinburgh nasal mucus from a horse supposed to 
have scarlatina, and w^ith it inoculated twelve children, all of w^hom had sores 
at the point of inoculation, with redness of the skin around the sores, and in 
some instances swelling of the adjacent lymphatic glands. It is stated that 
the children thus inoculated did not contract scarlet fever subsequently when 
they were exposed to it. Obviously, there is a serious objection to such 
experiments upon children, so that they may not be repeated. Children 
thus experimented on might, like the rabbits, die. The experiments involve 
too great a risk as regards the health and safety of the children experimented 
on. Under the circumstances the experimenter w^ho propagates so dangerous 
a disease by inoculation renders himself liable, it seems to me, to criminal 
proceedings in the courts. 

It is a matter of great interest and importance, and one not yet elucidated, 
whether or to what extent disinfectant and antiseptic remedies, administered 
internally, prevent the occurrence of the infectious maladies in those who 
have been exposed and aid in curing those who are sick with them. Sodium 
sulphocarbolate, from w4iich, by decomposition in the system, carbolic acid is 
supposed to be set free, has been used for this purpose. It is administered 
to adults in doses of ten to thirty grains, and to children in doses proportion- 
ate to their age. Declat has prepared a syrup of phenic (carbolic) acid as a 
preventive and curative agent in the infectious diseases. It is now" employed 
by several of the New" York physicians, but thus far the statistics of its use 
are not sufficient to determine its efficacy. It is a question whether the 
so-called antiseptics can, on account of their toxic properties, be used with 



TREATMENT. 311 

safety in doses sufficiently large to be antidotal to the specific principle of 
scarlet fever. 

In the present state of our knowledge the most reliable and certain 
prophylaxis is the isolation of patient and nurses and the thorough and 
judicious en)ployment of disinfectants upon their persons and in the apart- 
ments. All furniture and articles not absolutely required should be removed 
from the sick-room, and no one should be allowed to enter it except the med- 
ical attendant and nurses. Constant ventilation should be insisted on by 
lowering the upper and raising the lower sash of the window two or three 
inches in mild weather. Even in stormy weather sufficient ventilation can 
be obtained in this way without exposing the patient to currents of air, which 
should be avoided. 

The New York Board of Health enforces the following regulations to 
prevent the spread of scarlet fever as well as other acute infectious maladies : 

" Care of Patients. — The patient should be placed in a separate room, and 
no person except the physician, nurse, or mother allowed to enter the room 
or to touch the bedding or clothing used in the sick-room until they have 
been thoroughly disinfected. 

" Infected Articles. — All clothing, bedding, or other articles not absolutely 
necessary for the use of the patient should be removed from the sick-room. 
Articles used about the patients, such as sheets, pillow-cases, blankets, or 
clothes, must not be removed from the sick-room until they have been disin- 
fected by placing them in a tub with the following disinfecting fluid : eight 
ounces of sulphate of zinc, one ounce of carbolic acid, three gallons of water. 
They should be soaked in this fluid for at least an hour, and then placed in 
boiling water for washing. 

'' A piece of muslin one foot square should be dipped in the same solution 
and suspended in the sick-room constantly, and the same should be done in 
the hallway adjoining the sick-room. 

" All vessels used for receiving the discharges of patients should have 
some of the same disinfecting fluid constantly therein, and immediately after 
being used by the patient should be emptied and cleansed with boiling water. 
Water-closets and privies should also be disinfected daily with the same fluid 
or a solution of chloride of iron, one pound to a gallon of water, adding one 
or two ounces of carbolic acid. 

'• All straw beds should be burned. 

" It is advised not to use handkerchiefs about the patient, but rather soft 
rags, for cleansing the nostrils and mouth, which should be immediately there- 
after burned. 

" The ceilings and side-walls of a sick-room after removal of the patient 
should be thoroughly cleaned and lime-washed, and the woodwork and floor 
thoroughly scrubbed with soap and water." 

By such measures of prevention there can be no doubt that the number 
of cases of scarlet fever has been reduced. 

But do the health boards accomplish all that they are able to do in sup- 
pressing scarlet fever as well as diphtheria ? The New York Health Board 
excludes children from the schools who live in the houses where these diseases 
are occurring, gives directions in reference to the care of the patient and the 
disposition of infected articles, and promises to disinfect the sick-room when 
word is sent to the board. But these measures are inadequate or are only 
partially successful in preventing these diseases. To my knowledge, many 
families in New York never send word that they are ready for the disinfection 
of the apartments, and many families in the tenement-houses move away as 
soon as possible. The vacated rooms are re-rented to families who have no 
knowledge of the previous sickness, and are surprised when their children 



312 SCARLET FEVER. 

immediately after are taken sick. It would be better if the health board in 
every instance disinfected the infected apartments after the termination of 
the sickness, whether the family are willing or not. Moreover, the reader is 
referred to our remarks on the prevention of diphtheria for evidence of the 
inadequacy of the sulphur fumigation. In my opinion, fumigation both by 
burning sulphur and by chlorine, as employed by Prof. Doremus in Belle vue 
Hospital, should be used before the apartments are- reopened for occupancy, 
and the ceiling, walls, and floor should be washed with a corrosive-sublimate 
solution or other efficient antiseptic lotion. 

But the suppression of scarlet fever cannot be eifected without the 
co-operation of the attending physician. He can accomplish more than the 
health board in the way of prophylaxis. Twenty-one years ago the late 
Dr. William Budd of England recommended prophylactic measures, and 
the following is his testimony in regard to the result : " The success of 
this method in my own hands has been very remarkable. For a period 
of nearly twenty years, during which I have employed it in a very wide 
field, I have never known the disease to spread beyond the sick-room in a 
single instance, and in very few instances within it. Time after time I have 
treated this fever in houses crowded from attic to basement with children 
and others, who have nevertheless escaped infection. The two elements in 
the method are separation on the one hand and disinfection on the other." ^ 

In my opinion it is quite possible to realize the experience of Dr. Budd 
if proper prophylactic measures be employed from the beginning of the sick- 
ness. The attending physician at his first visit and at each subsequent visit 
should consider it an imperative duty to direct the employment of adequate 
preventive measures. Health boards give directions that objects not required 
to promote the comfort of the patient should be removed from the sick-room, 
and no one be allowed to ente'r it except the physician, nurse, and mother. 
The floor and walls of the apartment should be bare, but I would go farther 
than the health board, and insist that no reading matter, especially books and 
primers, be allowed in the room, or if allowed they should subsequently be 
burnt, since, as we have seen, the specific poison obtaining lodgment between 
the leaves is not readily reached by disinfectants, and may communicate the 
disease months afterward. I recommend for disinfection of the room at my 
first visit, and also for cases of diphtheria, the following prescription : 

R. Acidi carbolici, 

01. eucalypti, da. %] ; 

Spts. terebinth., 5vj. Misce. 

Two tablespoonfuls are added to one quart of water in a tin wash-basin or sim- 
ilar vessel with broad surface, and maintained in a state of constant simmering 
over a gas- or oil-stove during the entire sickness. The odor of this vapor is 
agreeable rather than unpleasant, and it appears to disinfect to a considerable 
extent the breath and exhalations from the body of the patient. At the 
same time, I order inunction of the entire surface every third hour with the 
following : 

R. Acidi carbolici, 

01. eucalypti, cici. ,^j \ 

01. olivoe, ^vij. 

Dr. Jamieson recommends disinfection of the fauces by the frequent 

application of a saturated solution of boracic acid in glycerin. This or 

some other non-irritating solution should be often applied, not only to the 

fauces, but also in the anginose cases to the nostrils. I have recommended 

^ British MedicalJournal, January 9, 1869. 



TREATMENT. 313 

the application of corrosive-sublimate solution, two grains to the pint, applied 
to the fauces by a camel-hair pencil or by cotton wadding wound around a 
slender stick, in the same manner in which Dr. Oatman and others employ it 
in diphtheria. 

The cautious physician in attending a case of scarlet fever will always 
bear in mind the possibility that his person or clothing may become infected, 
and be the vehicle through which the poison may be communicated to others. 
In examining the fauces of a patient he should stand a little to one side, so 
that no muco-pus, if the patient cough, be received on his clothing ; nor will 
he go directly from a scarlatinous patient to a child with another sickness, or 
to a midwifery case, without first washing his hands, hair, and face in a 
corrosive-sublimate solution, and changing his outer apparel ; or if he visit 
a child without such precautionary measures, he will not approach an}" nearer 
than is sufficient to enable him to determine its ailment and condition. 

Ht/gienic Treatment. — The room occupied by a scarlatinous patient should 
be commodious and sufficiently ventilated. Its temperature should be uni- 
form at about 70° during the course of the fever. When the fever begins to 
abate and desquamation commences, a temperature of 72° to 75° is prefer- 
able, so that there is less danger that the surface may be chilled during 
unguarded moments, as at night, when the body may be accidentally uncov- 
ered, since sudden cooling of the surface at this time may cause nephritis or 
some other dangerous inflammation. Henoch does not believe in the theory 
that the nephritis is commonly produced by catching cold, but many observa- 
tions show that those who are carefully protected from vicissitudes of tem- 
perature, who remain during convalescence in a warm room, and are pro- 
tected by abundant clothing, more frequently escape this complication than 
such as are under no restraint of this kind and are carelessly exposed in times 
of changeable weather. Nevertheless, it is true that a certain proportion 
suifer from nephritis however judicious the after-treatment may be. The 
best hygienic management does not always prevent its occurrence. The 
patient should not, therefore, leave the house until four weeks after the 
beginning of the fever, and in inclement weather not till a longer time has 
elapsed. So long as desquamation is going on and the skin has not regained 
its normal function, the patient should remain indoor, and when finally he is 
allowed to leave the house he should be warmly clothed. 

Therapeutic Treatment. — In order to treat scarlet fever successfully, it is 
necessary to bear in mind that it is a self-limited disease, running a certain 
time and through certain stages, and that it is not abbreviated by any known 
treatment. Therapeutic measures can only moderate its symptoms and ren- 
der it milder. The severity of the disease is indicated by its symptoms, and 
the symptoms are to a certain extent under our control. 

Mild Cases. — A patient with a temperature under 103° and with only a 
moderate angina does not require active treatment, but, however light the 
disease, he should always be in bed and in a room of uniform temperature, 
as stated above. - Instances have come to my notice in the poor families of 
New York in which scarlet fever was not diagnosticated, and the patients 
were allowed to go about the house, and even in the open air, in the eruptive 
stage, till some severe complication or an aggravation of the type created 
alarm and medical advice was sought, when it appeared that a grave and dan- 
gerous condition had, through carelessness and ignorance, resulted from a 
mild and favorable form of the malady. The physician, when summoned to 
a case however mild, should never fail to take the temperature, note the 
pulse, inspect the fauces, and inquire in reference to the fecal and urinary 
evacuations, that he may detect early any unfavorable changes which may 
occur. 



314 SCARLET FEVER. 

Since in all cases angina and more or less blood-deterioration are present, 
the following prescription will be found useful in mild as well as severe scar- 
let fever : 

R. Potass, chlorat., ^ss; 

^ Tr. fei-ri chloridi, f:^ij ; 

Syrupi, f^iV. Misce. 

Sig. : Dose, one teaspoonful every hour to two hours to a child of three years 

Small doses of this medicine frequently administered act beneficially on the 
surface of the throat and tend to prevent the anaemia which is so common 
after scarlet fever. If the medicine be given gradually, diluted with only a 
moderate amount of water, the effect is better on the inflamed fauces. Potas- 
sium chlorate is known to be an irritant to the kidneys in large doses, caus- 
ing intense hyperasmia of these orgaUvS, with bloody urine or suppression of 
urine. The melancholy fate of Fountaine, who died from the effects of one 
ounce of this medicine, is known to the profession. I have seen a similar 
instance in a child. But doses of half a grain to two grains, according to 
the age, can be administered with safety to children, so that twenty to thirty 
grains are taken in twenty-four hours. A quantity much exceeding this 
amount involves risk. 

R. Qninise snlphat., gr. xvj ; 

Syr. priini virginiani, 

Syr. yerbse santse comp., da. ^j. Misce. 

Sig. : One teaspoonful every fourth hour to a child of three to five years, the potassium 
chlorate and iron mixture being administered twice between. 

The treatment of scarlatina by antiseptic remedies will be considered 
hereafter. 

The itching and dryness of the surface, which increase the discomfort of 
the patient in mild as well a.s severe scarlatina, are relieved by the ointment 
mentioned in treating of prophylaxis. The linen should be changed every 
day and the bed thoroughly aired. 

Ordinary Coses and Cases of Severe Type. — A safe temperature in scarlet 
fever may be considered at or below 103°. If it rise above this, measures 
designed to abstract heat are very important — more important even in many 
cases than the medicinal agents which are commonly used to combat this 
disease. Since a high temperature retards assimilation, promotes deleterious 
tissue-change, and causes rapid emaciation and loss of strength, measures 
designed to reduce it are urgently needed. " The production of heat depends 
chiefly on oxidation of the constituents of the body" (Billroth). Therefore, 
fever indicates an increase of the oxidation and a molecular disintegration 
above the healthy standard. Hence the augmentation of urea in the urine 
and the progressive emaciation and loss of weight which characterize the 
febrile state. Fever also diminishes the secretions by which food is digested 
and destroys the appetite, so that repair of the waste is insufficient. More- 
ever, a high temperature continuing for a time tends to produce degenerative 
changes, albuminous and fatty, in the tissues, the more rapidly the higher 
the temperature, so that the functions of organs are seriously impaired. 
Among the most dangerous of the tissue-changes is granulo-fatty degenera- 
tion of the muscular fibres of the heart. In dogs and rabbits that have per- 
ished from a high temperature artificially produced by experimenters gran- 
ular clouding of the elementary tissues has been found after death.^ A high 
temperature, therefore, in itself involves danger, and if it occur in an ataxic 

^ See experiments by Mr. J. W. hegg, Land. Path. Soc. Trans., vol. xxiv., and 
others. 



TREATMENT. 315 

disease like scarlet fever, and be protracted, it greatly diminishes the chances 
of a favorable issue. 

The temperature can be reduced without shock or injury to the child by 
the judicious use of cold water externally. The cold-water treatment is not 
necessary if the temperature be under 103°, though useful if judiciously 
employed by sponging when the temperature is at 102° or 103° ; but if it 
rise above 103° it is required, and the more urgently the higher the tempera- 
ture. The external use of cold water as an antipyretic in the febrile diseases 
is now almost universally recommended by physicians, but it still meets with 
opposition on the part of families, especially in the treatment of the exanthe- 
matic fevers, and the directions for its employment are therefore not likely to 
be fully carried out during the absence of the medical attendant. The old 
theory that the fevers require warmth and sweating has such a firm hold on 
the popular mind that some years longer will be required for its removal. 

The modes of applying cold water recommended by cautious and expe- 
rienced physicians are various. Yon Ziemssen recommended that the patient 
be immersed in water at a temperature of 90°, and cool water be gradually 
added till the temperature fall to 77°. In a few minutes the patient is 
returned to his bed, his surface dried, and he is covered by the proper bed- 
clothes, when his temperature will probably be found reduced two or two and 
a half degrees. If the patient complain of chilliness or his pulse be feeble, 
he should be immediately removed from the bath and stimulants administered, 
either whiskey or brandy, for if the extremities remain cool and the capillary 
circulation sluggish, the effect may be injurious, since some internal inflam- 
mation may arise to complicate the fever. Under such circumstances increased 
alcoholic stimulation is required. 

The cold pack is also effectual for reducing the temperature. The patient 
is placed upon a mattress protected by oil cloth, and is covered by a sheet 
wrung out of water at a temperature of 70°, This is covered by one or two 
blankets. In half an hour he is returnedto bed, and will be found to have a 
temperature two or three degrees less than that before the bath. Another 
method is to appl}' the sheet wrung out of water at 90°, and then reduce the 
temperature by adding water at a lower degree from a sprinkler. In most 
cases, however, I prefer to reduce the temperature by the constant application 
to the head of an India-rubber bag containing ice. The bag should be about 
one-third filled, so that it should fit over the head like a cap. At the same 
time, as a potent means of abstracting heat, at least when the temperature is 
at or above 104°, a similar application should be made by an elongated rub- 
ber bag lying over the neck and extending from ear to ear. Cold applied 
over the great vessels of the neck promptly abstracts heat from the blood, 
while it diminishes the pharyngitis, adenitis, and cellulitis ; which is an 
important gain. At the same time, it is proper to sponge frequently the 
hands and arms with cool water. If the temperature with this treatment be 
not sufiiciently reduced, one or two thicknesses of muslin frequently wrung 
out of ice-water should be placed along the arms and upon either side of the 
face. By such local measures, which are agreeable to the patient and with- 
out shock or perturbing effect on the s^^stem, we can reduce the temperature 
two or three degrees. By adding alcohol or one of the alcoholic compounds 
to the water the popular objection to the use of cold is overcome. 

Trousseau, in the treatment of sthenic cases attended by a high tempera- 
ture, was in the habit of placing the patient naked in a bath-tub, and directing 
three or four pailfuls of water to be thrown over him in a space of time vary- 
ing from one-quarter of a minute to one minute after which he was returned 
to bed and covered by the bedclothes without being dried. Reaction imme- 
diately occurred, often with more or less perspiration. This treatment was 



316 SCARLET FEVER. 

repeated once or twice daily, according to the gravity of the symptoms. 
Trousseau, alluding to this treatment, says : " I have never administered it 
v^ithout deriving some benefit." But the application of cold water in a man- 
ner that does not excite or frighten the patient seems preferable. Henoch, 
having a large experience, gives the following advice in reference to the water 
treatment : " If the fever continue high and the apparently malignant symp- 
toms described above develop, the head should be covered with an ice-bag, 
. . . . and the child placed in a lukewarm bath, not under 25° K. (88.25° F.). 
I decidedly oppose cooler baths, because in scarlatina, which presents a tend- 
ency to heart-failure, cold may produce an unexpected rapid collapse more 
than in any other affection. But I strongly recommend washing the entire 
body every three hours with a sponge dipped in cool water and vinegar."^ 
In grave cases with a high temperature the application of cold should be suf- 
ficient to produce a decided reduction of heat, otherwise the full benefit from 
its use is not obtained- With proper stimulation and proper precautions 
prostration does not occur from the ice-bags to the head and neck and cool 
sponging of other parts so long as the temperature does not fall below 102° 
or 103°. The danger alluded to by Henoch can only occur from the use of 
the pack or general bath, and the water treatment can be efficiently carried 
out and the temperature sufficiently reduced without resorting to these. 
Even Currie of Edinburgh, who first drew attention to the benefit from the 
cold-water treatment of scarlet fever in an age when the sweating treatment, 
and even the exclusion of cool and fresh air from the apartment, were deemed 
necessary, recommended cold effusion only in sthenic cases with full and strong 
pulse ; and he mentions as a warning two cases with quick and feeble pulse 
and cool extremities in which death occurred immediately after the use of the 
water. 

Sodium salicylate is in some instances a useful remedy for the reduction 
of heat in the infectious diseases. It seems to be more decidedly antipyretic 
than quinine in the febrile and inflammatory diseases, though somewhat 
depressing to the heart's action. James Couldrey writes to the London 
Lancet (Dec, 1882, p. 1064) that he has derived great benefit from its use in 
seven cases of scarlet fever. He administered it every two hours till ringing 
in the ears was produced, and afterward every four hours, prescribing one 
grain for each year in the age of the patient. It is, in my opinion, a proper 
remedy when the pulse is full and strong and the temperature is not suf- 
ficiently reduced by the cold-water treatment. 

Aconite and veratrum viride reduce fever, but they are too depressing to 
be safely employed in grave scarlet fever, and their antipyretic effect is less 
than that of water. The use of digitalis might be suggested by the quick 
and feeble pulse in certain cases that are attended by high temperature, but 
the judgment of the profession is for the most part against its use in such 
cases. What Stille and Maisch state of its employment in typhoid fever 
appears equally applicable to scarlet fever : " Even its advocates have not 
shown that it abridges the disease or lessens its mortality, while it is abun- 
dantly demonstrated to impair the digestion, reduce the strength, and even 
to occasion sudden death. The use of digitalis in other forms of fever is 
equally unsatisfactory, and justifies the judgment of Traube, that the true 
field of action for digitalis is not fever." 

Quinine is the medicine which above all others has been heretofore most 
used, by almost common consent of the profession, to reduce the temperature 
in malignant scarlet fever, but its use for this purpose is, according to my 
observations, far from satisfactory. To obtain its antipyretic action it must 
be administered in large doses, and if any of the quinine salts in ordinary 

^ Diseases of Children. 



TREATMENT. 317 

use be administered by the mouth in sufficient quantity, they are liable to' be 
vomited. To a child of five years five grains should be administered twice 
daily by the mouth, or ten grains of a soluble salt, as the bisulphate, may be 
given per rectum, dissolved in a little warm water. Administered per rectum, 
it is frequently not retained unless held for a time by a napkin. When the 
antipyretic doses of quinine are discontinued, this agent may be prescribed as 
a tonic in doses recommended for the treatment of mild scarlet fever. 

Antipyrine and antifebrin are efficient and certain antipyretics, but in dis- 
eases attended by depression they are not safe remedies. When employed in 
such diseases the physician should visit the patient at short intervals, so that 
the medicine may be omitted if the action of the heart becomes feeble. When 
these agents are employed an alcoholic stimulant should be given at the same 
time. In my practice antipyrine has been more employed than antifebrin. If 
the patient have a temperature at or above 105°, not reduced by the cold 
bathing or by the sodium salicylate or quinine, and especially if the patient 
have jactitation and delirium, so that convulsions are imminent, the threat- 
ening danger may perhaps be averted by prescribing three to five grains of anti- 
pyrine, with double or treble its amount of bromide of sodium or potassiuni, 
to be given at intervals of three hours. The preferable antipyretic is, how- 
ever, in my opinion, phenacetin, which can be given in powder every third 
hour in doses of two or three grains, with or without the bromide, to a child 
of five years. 

In severe cases with frequent and rapid pulse, in which ante-mortem 
heart-clots are liable to occur, the ammonium carbonate is often useful. It 
should be dissolved in water and given in milk in as large doses as three grains 
every hour or second hour to a child of five years. It aids in producing 
stronger contraction of the cardiac muscular fibres, and thus diminishes the 
danger of the formation of thrombi. Ten-drop doses of the aromatic spirits 
of ammonia may be employed instead of the carbonate, given in sweetened 
water. It is especially useful if the stomach be irritable. A wineglassful 
of milk should be employed for this purpose, so that the medicine do not 
eause gastritis. 

In severe cases attended by considerable angina and foul and offensive 
secretions upon the faucial surface an antiseptic, as boracic acid, in small 
quantity should be added to the potash and iron mixture recommended 
above. If no drink be allowed for a few minutes after the dose, so as not 
to wash it too soon from the fauces, the antiseptic effect is more certainly 
produced. Those old enough should be directed to hold the medicine for a 
moment like a gargle in the throat before swallowing it. I employ boracic 
acid by preference, as in the following formula : 

IJ. Acid, boracic, ,^ss ; 

Potass, chlorat., J^ss ; 

Tr. ferri chloridi, f^ij J 

Glycerini, --/.-?• 

Syrupi, ««-^^J' 

Aqnee, f^ij. Misce. 
^ig. : Give one teaspoonful every two hours to a child of five vears. 



More minute directions will presently be given for the treatment of the 
pharyngitis when we speak of the complications. 

Alcohol, whether administered in one of the stronger wines, as sherry, or 
in whiskey or brandy, is a most useful remedy in scarlet fever, and is indeed 
indispensable in all grave cases which are attended by feeble capillary circu- 
lation and evidences of prostration. Milk is also the best vehicle for this 
agent. The wine-whey or milk-punch should be given every hour or sec- 



318 SCARLET FEVER. 

ond hour. In scarlet fever, as well as diphtheria, comparatively large doses 
are required, as a teaspoonful of the stimulant every hour or second hour 
for a child of five years. 

During convalescence the hygienic treatment already described is import- 
ant. Nutritious diet and a moderate amount of alcoholic stimulants are 
required, while the patient is kept indoor and protected from currents of 
air as long as desquamation is occurring. More or less anaemia is present 
in most convalescent patients, so that a mild tonic containing iron will aid 
in restoring the health. Elixir of calisaya-bark and iron, preparations of 
beef, iron, and wine, or the liquor ferripeptonati in teaspoonful doses will be 
found useful under such circumstances. 

Antiseptic Treatment. — As stated above, it is still undetermined whether or 
to what extent antiseptics, administered internally, antagonize and control the 
scarlatinous poison, and are therefore curative of scarlet fever. An important 
agent of this class, carbolic acid, can only be employed in small doses, for a 
dose much exceeding a drop for a child, or even exceeding a fractional part 
of a drop for a young child, might produce poisonous symptoms. Carbolic 
acid is a cardiac and arterial sedative, and it appears to reduce temperature. 
Intra-uterine injections of carbolized water in the treatment of puerperal 
fever are known to reduce temperature, even when there is no septic matter 
in the uterus to be disinfected and washed away, as in the case related to me 
in which the fever proved to be due to measles. It is not improbable that 
the antipyretic action in patients of this class who have no septic substance 
within the uterus is due largely, if not mainly, to the absorption of carbolic 
acid from the uterine surface and its sedative action on the vascular system. 
Whether this agent, so highly extolled by Declat, and to which I have alluded 
in a preceding page, can be safely employed in doses large enough to be 
efficient and curative, will be determined by future observations. Since 
scarlet fever resembles diphtheria in many particulars, it is a proper ques- 
tion whether the antiseptic remedies now largely used in the treatment of 
diphtheria, and with apparent benefit, may not be useful in scarlet fever. 
The sulphocarbolate of sodium has indeed been employed internally in scar- 
latina, with alleged benefit. Its antiseptic action is attributed to the carbolic 
acid in its composition, which is set free. It is certainly a useful remedy 
in severe anginose scarlet fever with fetid breath, whether used internally or 
as a gargle. It may be given in doses of five grains, dissolved in water, every 
three hours to a child of five years. In the gangrenous pharyngitis of scar- 
let fever probably the gargles or sprays of the corrosive-sublimate solution 
may be useful, as they are in diphtheritic pharyngitis. The apparent benefit 
derived from- the internal use of corrosive sublimate in diphtheria suggests 
its internal use also in scarlet fever, but it has seldom been employed in this 
manner. 

Treatment of Complications and Sequelse,. — Local measures designed to 
diminish or cure the pharyngitis are important in all but the mildest cases. 
They are more especially required in the anginose variety and in those not 
infrequent cases in which diphtheria complicates scarlatina. Formerly it 
was necessary, in making applications to the fauces, to employ the brush or 
probang for those too young to use the gargle, but hand-atomizers, as Rich- 
ardson's or Delano's, which are now in common use, aff^ord a quick and easy 
method for making such applications. Six or eight compressions of the bulb 
of a good atomizer are sufficient to cover the fauces with the spray. Those 
hand-atomizers in the shops which have slender metallic points are likely to 
prick the buccal surface and cause bleeding if the child resist and toss the 
head. To prevent this, I am in the habit of directing India-rubber tubing 
to be drawn over the point in such a way as not to obstruct its action. The 



TREATMENT. 319 

following will be found useful mixtures for the atomizer : For ordinary 
cases, 

R. Acidi carbolici, ^ss, vel. Acid, boracic, 31] ; 

Potass, chloral., 5J 5 

Glycerini, f^ij ; 

Aquae, f^vj. Misce. 

If the surface of the throat be covered by foul secretions, 



R. Acidi carbolici, 


5ss; 




Potass, chlorat., 


.^j; 




Glycerini, 


flj; 




Aquae calcis, 


f5vij. 


Misce. 



If diphtheritic exudation complicate the scarlatinous angina, or the surface 
of the throat in consequence of ulceration or necrosis present an appearance 
like that in diphtheria when the exudation begins to soften, being foul, 
jagged, of a dirty-brown appearance from dead matter and fetid secre- 
tions, those mixtures for spraying the throat will be found useful which 
are recommended in our remarks relating to the local treatment of diph- 
theria. 

The following mixture is also beneficial for local treatment when the 
faucial surface is foul and offensive from the exudations and secretions. 
It should be applied by a large camel's-hair pencil every three to six 
hours : 

R. Acidi carbolici, gtt. x ; 

Liq. ferri subsulphatis, fjij ; 

Glycerinee, fgj. Misce. 

In all cases of scarlatinous pharyngitis sufficiently severe to require 
special treatment, cool applications should be made over the neck from ear 
to ear, as by two thicknesses of muslin frequently squeezed out of cold water, 
or by the elongated India-rubber bag already recommended in our remarks 
relating to the methods to reduce temperature. 

In the first days of scarlet fever the coryza is slight and no discharge 
from the nostrils occurs, so that no local treatment is required; but before 
the termination of the malady, in cases of ordinary gravity, a nasal dis- 
charge usually supervenes, producing more or less redness and excoriating 
the upper lip. Moreover, in localities where diphtheria occurs, if this mal- 
ady complicate scarlet fever, it usually affects the nostrils at the same time 
that the fauces are invaded. These conditions require local treatment of the 
nares. It should be remembered that the Schneiderian membrane is midway 
in sensitiveness, as it is in location, between the conjunctival and buccal sur- 
faces, and is readily irritated by strong applications. Medicinal applications 
made to it must be much milder than those which the fauces tolerate. They 
should always be applied warm, and a teaspoonful of any mixture properly em- 
ployed is sufficient for each nostril at one sitting. The applications should 
usually be made every two to four hours, according to the gravity of the case 
and the amount of the discharge. The best instrument for this purpose is 
a small syringe of glass with curved neck and bulbous tip. The child's 
head should be thrown back and the piston depressed rapidly, so as 
thoroughly to wash out the nasal cavity. The application can also be made 
through an atomizer with a rounded tip or a tip covered by rubber tubing. 
The following is a useful prescription : 



320 SCARLET FEVER. 

R. Acidi borici, .5j ; 

Sodii biborat., .^ij ; 

Aquae purse, Oj. Misce. 

It is evident, from what has been stated above, that the condition of the 
ear should be closely observed in and after scarlet fever. If the patient have 
earache, considerable relief may be obtained in the commencement by drop- 
ping a few drops of laudanum and sweet oil into the ear and covering it by 
some hot application, either dry or moist, which will retain the heat. A light 
bag containing common table-salt, heated, or dry and hot chamomile-flowers, 
will also answer the purpose. Water as hot as can be well tolerated dropped 
into the ear or allowed to trickle from a fountain syringe, so as to fill the ear, 
is also very beneficial in allaying the pain. A 4 per cent, solution of nitrate 
of cocaine, with an equal quantity of laudanum, dropped into the ear, will 
often give considerable relief. If the hot applications over the ear are not 
well borne, Dr. C. H. May, aurist, recommends applying a long and narrow 
ice-bag imme'diately behind the auricle and extending under and in front of 
the ear, so as to cover the temporo-maxillary region, and at the same time 
instilling into the ear hot salt water (5J to Oj), to which laudanum or cocaine 
is added. He also states that antipyrine in large doses is also useful in 
relieving the pain.^ If the pain be not quickly relieved, a leech should be 
applied at the base of the tragus. 0. D. Pomeroy, an experienced aurist of 
New York, says : " Leeching employed at the right time rarely fails to sub- 
due the pain and inflammation. The posterior face of the tragus is ordinarily 
the best place for applying the leech, but it may be applied in front of the 
ear or behind, wherever the tenderness on pressure is greatest. In my 
opinion, paracentesis may frequently be rendered unnecessary by the timely 
use of one or two leeches applied to the meatus." 

If the otitis continue, as shown by pain in the ear, of which children old 
enough to speak bitterly complain, and which causes those too young to speak 
to press their fingers into or against their ears, this inflammation should not 
be neglected, as it may involve serious consequences. Multitudes of children 
have had permanent impairment or even loss of hearing, with caries or necro- 
sis of the walls of the middle ear and of the mastoid cells, which might have 
been prevented by prompt and skilful management of the ear in the early 
stage of the inflammation. If, therefore, the otitis continue without mitiga- 
tion of pain after the above measures have been employed, paracentesis of 
the drumhead is probably required. The following directions for performing 
this operation, which will be useful to country practitioners who may not be 
able to obtain the assistance of a specialist, are furnished by Dr. Pomeroy : 
'•The forehead mirror should be worn, in order to leave the hand free to 
operate by either artificial or day light. A good-sized speculum is introduced 
into the meatus. Then an ordinary broad needle, about one line in diameter, 
with a shank of about two inches, such as oculists use for puncturing the 
cornea, should be held between the thumb and fingers, lightly pressed, so as 
not to dull delicate tactile sensibility. The part being well under light, the 
most bulging portion of the membrane should be lightly and quickly punc- 
tured with a very slight amount of force. The posterior and superior por- 
tion of the membrane is the most likely to bulge. The chordae tympani 
nerve ordinarily lies too high up to be wounded. The ossicles are avoided 
by selecting a posterior portion of the membrane. After puncture the ear 
should be inflated by an ear-bag whose nozzle is inserted into a nostril, both 
nostrils being closed^^ so as to force the fluid from the tympanum. The punc- 
ture may need to be repeated at intervals of a day or two, provided that the 
id bulj, 

Pediatric Sec. of N. Y. Acad, of Med., March 14, 1889. 



TREATMENT. 321 

Albert H. Buck of New York, in a liigbly instructive paper read before 
the International Medical Congress in 1876, writes as follows of paracentesis 
of the membrana tympani in scarlatinous otitis: "In this one slight opera- 
tion, which in itself is neither dangerous nor very painful, lies the power to 
prevent the whole train of disagreeable and dangerous symptoms." Buck 
relates an instructive example : The age of the patient was three years, and 
the earache had been complained of only about twenty-four hours. " Toward 
morning," says he, " I was sent for, as the pain had become constant. ... 
An examination with the speculum and reflected light showed an (edematous 
and bulging membrana tympani (posterior half), the neighboring parts being 
very red, though as yet but little swollen. In the most prominent portion 
of the membrane I made an incision scarcely three millimetres (one-tenth 
inch) in length, and involving simply the different layers of the membrana 
tympani. This was almost immediately followed by a watery discharge (with- 
out the aid" of inflation), which ran down over the child's cheek. At the end 
of three or four minutes the child had ceased crying, and in less than a quar- 
ter of an hour she was fast asleep. At first the discharge was very abun- 
dant and mainly watery in character, but it steadily diminished in quantity 
and became thicker, till finally, on the fourth day, it ceased altogether. On 
the tenth day the most careful examination of the ear could not detect any 
trace of either the inflammation or the artificial opening." The ear had prob- 
ably been saved from ulceration of the drum membrane, long-continued sup- 
purative otitis, and perhaps permanent impairment of hearing. 

When an opening has been made in the membrana tympani, either by 
incision or ulceration, it is advisable in some instances to inflate the tym- 
panum by Politzer's method, which has been alluded to above. The nozzle 
of an India-rubber bag with a flexible tube attached is introduced into the 
nostril on the affected side, and both nostrils are compressed against it. The 
patient fills his mouth with water, which he swallows at a given signal, as 
after the words one, two, three, spoken by the operator. During the act of 
swallowing, which opens the Eustachian tube, the rubber bag is forcibly com- 
pressed, which forces the air along the tube into the middle ear and facilitates 
the escape of the pent-up secretions in the tympanic cavity. Dr. May recom- 
mends cleansing the nostrils and pharynx with a warm solution of salt, one 
drachm to the pint, before the use of Politzer's bag. 

If the otitis have continued unchecked by treatment until the secretions 
within it, after days and nights of suffering, have escaped by ulceration 
through the drumhead, the opportunity for prompt and certain cure is passed. 
Still, the patient under these circumstances may quickly recover, or there 
may be the other alternative described above, in which the ear is badly dam- 
aged and chronic inflammation established in the walls of the tympanum, 
giving rise to an offensive otorrhoea. In this state of the ear internal rem- 
edies are indicated, such as surgeons employ in suppurative inflammations of 
bone occurring in other parts of the system. Cod-liver oil and iodide of iron 
are required, espeeially by patients of strumous diathesis, the object being to 
promote a more healthy state of system, so as to prevent extension of the 
inflammation and facilitate the healing process. Carbolized solutions, as the 
following, syringed warm into the ear in which otorrhoea is occurring, are 
useful in promoting cleanliness and increasing the comfort of the patient : 

K. Acidi carbolici, .^ss; 

Glycerini, f^ij ; 

Aquee, f^iv. -Misce. 

But recently an effectual curative agent for local treatment has been discov- 

21 



322 SCARLET FEVER. 

ered in boracic acid, by the use of which the discharge quickly diminishes 
and the condition of the ear more certainly and rapidly improves than by the 
use of the carbolized lotions. 

R, Acidi borici, ^ijss; 

Glycerini, 

Aquse, da. f^j. 

Sig. : Instil sufficient to fill the external ear three or four times daily. 

The beneficial effects observed from the use of boracic acid in aural sur- 
gery have given it nearly the same position as a curative agent to diseases 
of the ear which atropine holds to diseases of the eye. Recently aurists 
are employing finely triturated powder of boracic acid dusted into the ear. 
The patient lies upon the side with the affected ear uppermost. The ear is 
thoroughly cleaned by syringing with tepid water, and by means of a little 
scoop made of stiff paper or pasteboard or the segment of quill as much of 
the powder is introduced into the ear as will cover a five-cent silver piece. 
By working the ear it descends to the drumhead. I can bear witness to its 
efficacy in the otorrhoea of children when it is used in this manner three times 
daily. 

The following astringent has also been employed with good results for 
the otorrhoea resulting from scarlet fever as well as from other causes : 

R. Zinci sulphatis, 

Aluminis, da. gr. v ; 

Aquae, f^. Mi see. 

A few drops of this should be dropped into the ear, or, if the ear be sensitive 
and painful, five drops should be added to a teaspoonful of warm water and 
dropped or syringed into the ear. 

But in recent times aurists have discovered a remedy superior to the 
above in iodoform, the action of which is safe and efficient for protracted 
otorrhoea with granulations, and it is superseding to a great extent the agents 
heretofore used in the treatment of this disease. The ear should first be 
thoroughly cleaned by syringing with warm water and dried, and iodoform, 
to which a little balsam of Peru is added to mask the disagreeable odor, 
should be pressed down to the bottom of the auditory canal by any conveni- 
ent instrument. It is anodyne, astringent, and disinfectant, and should be 
employed in a dry state in considerable quantity. 

The sequelae of otitis media, such as granulations sprouting out from the 
drumhead, some of which may be of large size and are known as polypi, may 
require treatment by the aurist. A polypus may sometimes be removed by 
the forceps, or, better, by the snare. Polypi not large and favorably located 
can sometimes be cured by an astringent powder, as iodoform, sulphate of 
zinc, or alum, or by applying the liquid subsulphate of iron. The otitis 
externa produced by the irritating discharge which flows from the middle ear 
soon disappears when the flow ceases. 

The renal affection — which, as we have seen, so often commences in the 
declining period of scarlet fever or during convalescence in mild as well as 
severe cases — is frequently more dangerous than the primary disease." It 
largely increases the percentage of deaths. A clear appreciation of its thera- 
peutic requirements is important, since by judicious treatment many recover 
who would inevitably be sacrificed by improper measures. The family should 
be informed that the danger from scarlet fever does not cease with the decline 
of the eruption, and that the kidneys may become seriously affected by too 
early exposure of the patient to currents of air or sudden changes of tem- 



TREATMENT. 323 

perature, by which cutaneous transpiration is checked. He should therefore 
be kept indoor in a comfortable and uniform temperature three or four weeks 
after the termination of the fever, until desquamation has entirely ceased and 
the new epiderm is sufficiently thick and firm to protect the surface. During 
the changeable temperature of the autumnal, winter, and spring months even 
longer confinement at home may be advisable. 

The nephritis and consequent albuminuria antedate by some days the 
occurrence of dropsy, and a physician should never discharge a scarlatinous 
patient without one or more examinations of his urine. When his visits 
cease the nurse should be instructed to make the examinations by heat and 
nitric acid during the ensuing month, and if any evidence, however slight, 
appear that the kidneys are involved, he should be notified, in order that 
appropriate treatment may be immediately commenced. Early and correct 
treatment of the nephritis is attended by much better results than delayed 
treatment, and many more patients are doubtless now saved than in former 
times, when little attention was given to the state of the kidneys until dropsy 
or other prominent symptoms appeared. I have found no mother or nurse 
so ignorant that she could not properly employ the test of nitric acid and 
heat, and if she be solicitous for the welfare of the child, she will not hesi- 
tate to carry out the directions and immediately notify the physician if the 
tests employed produce the least cloudiness or turbidity of the urine. 

The patient as soon as nephritis commences, as shown by the state of the. 
urine, should be put to bed in a room of warm and equable temperature (72° 
to 75° F.). His diet should be liquid, consisting of milk, farinaceous food, 
and a moderate quantity of animal broths. He may drink liquids freely, 
especially water not too cool, to which spiritus setheris nitrosi is added. If 
he be prostrated by the primary disease, alcoholic stimulants should be allowed. 

The indications are to relieve the hypergemic kidneys by diaphoresis and 
purgation. To produce the former the patient should be immersed in a warm 
bath at about the temperature of the body (98° to 100°), in which, if he be 
quiet and comfortable, he should remain from fifteen to twenty minutes, but 
a shorter time if restless and frightened by the water, after which he should 
be placed in a warm bed and well covered by blankets. Tf perspiration result, 
the bath has been useful, and it may be employed in grave cases two or three 
times daily. If perspiration do not result, it may be produced by surround- 
ing the body either by hot dry or moist air. Hot air may be produced by 
burning alcohol in a thin layer upon a plate under a chair, upon which the 
patient sits while he is surrounded by a blanket, or he may be covered in bed 
and the hot air introduced under the bedclothes. In New York a convenient 
apparatus is used for this purpose, consisting of a small sheet-iron pipe 
enclosed in a small box of the same material. The box is in the form of a 
trunk, with a handle for convenience in carrying, and the lower end of the 
pipe, which extends nearly to the floor, contains an alcohol lamp. Hot moist 
air may be produced by placing against the patient bottles of hot water sur- 
rounded by towels wrung out of water. The steam arising from them and 
enveloping the body and limbs produces a prompt sudorific effect. There is 
in use in this city, in the treatment of these and similar cases requiring 
diaphoresis, a convenient apparatus for generating steam. It consists of a 
cylinder pierced with holes for the admission of air and containing a spirit 
lamp, over which is a pan or pail holding a little water. The patient, nearly 
naked, is placed in a chair with the apparatus underneath, and is covered by 
a blanket, so that the steam surrounds the body. This gives rise to free 
perspiration, which continues after the patient is placed in bed. This treat- 
ment should be repeated one or more times daily, according to the gravity of 
the case. 



324 SCARLET FEVER. 

The sudorific effect of the treatment by external warmth described above 
should be aided by employing diaphoretics. Those which have been most 
used are the acetates of ammonium and potassium, the bitartrate and citrate 
of potassium, and spiritus aetheris nitrosi. If employed when the surface is 
cool they act rather as diuretics than diaphoretics. These agents, being 
simple in their action and without deleterious effect, may be given frequently 
and in large proportionate doses for the age. 

But lately a diaphoretic which far surpasses these in efficiency has been 
discovered in pilocarpine, the active principle of jaborandi. Being soluble in 
water and tasteless, it is easily administered, and is retained when, on account 
of the urasmic poisoning present in scarlatinous nephritis, the stomach is 
irritable and other medicines, as digitalis, are rejected. Ether may be 
employed with it, or the amount of alcoholic stimulant may be increased 
at the time of its exhibition in order to guard against any depressing effect. 
To a child of two years one-fortieth to one-twentieth of a grain may be given 
every six hours by the mouth. It may also be employed hypodermically, as 
one-twentieth of a grain to a child of five years. It has both a diaphoretic 
and a diuretic action, while it stimulates both the salivary and mucous secre- 
tions. According to one observer, an adult when fully under the influence 
of pilocarpine secretes from one pint to one quart of saliva within two hours, 
and Leyden reports a case of diphtheritic nephritis in which the quantity of 
urine rose from half a pint to five pints daily. But its most prompt and 
certain action is upon the sweat-glands. Hirschfelder speaks of its beneficial 
action in relieving various forms of dropsy, and adds : " In one morbid con- 
dition of the kidney, however, jaborandi is the remedy par excellence, and 
that is the acute parenchymatous nephritis which frequently follows scar- 
latina This disease heals spontaneously if the danger that threatens 

life from reduction of the urine and from the efiusions of fluid into the cav- 
ities of the body be averted. In this disease jaborandi works wonders." I 
have also found it an invaluable agent when the older remedies failed and 
death seemed imminent. The following cases, in which the beneficial action 
of this agent was apparent, occurred in my practice : 

Case 1. — G , male, aged five years and six months, sickened with scarlet 

fever on June 2, 1882. It began with vomiting, and was attended by a degree of 
fever which indicated an attack of rather more than the average gravity. The 
fauces at one time exhibited a slight exudation like that of diphtheria. In 
the declining stage of the malady rheumatic pain and tenderness occurred 
in the wrist- and finger-joints, but not in those of the lower extremities. The 
case, however, progressed favorably, and during the convalescence my attend- 
ance ceased. On June 24th my attention was again called to the child, when 
the urine was found to be scanty and very albuminous. External measures, such 
as are described in the foregoing pages, were employed, and the infusion of digi- 
talis with potassium acetate ordered to be given every three hours; but this med- 
icine was for the most part vomited. The bowels were kept open by jalap and 
the potassium bitartrate. The urine, however, continued scanty, and on June 
28th severe convulsions occurred. At this time the quantity of urine was only 
f5ij in twenty-four hours. The pulse in the convulsions was quick and feeble, 
tiie skin very hot, and the axillary temp. 103°. The eclampsia continued one hour, 
and was controlled by large and repeated doses of bromide of potassium, aided by 
clysters of five grains of hydrate of chloral in water. Muriate of pilocarpine was 
now directed to be given in doses of one-thirty-second of a grain every three 
hours, dissolved in cold water. This agent was not vomited, and it must have 
been given by the parents in the fright and anxiety in larger or more frequent 
doses than were directed, for on July 1st the bottle containing one grain was 
empty. Free diaphoresis resulted from the pilocarpine, and the quantity of 
urine was increased. The mother stated that the child had taken only two doses, 
or one-sixteenth of a grain, of pilocarpine when the diuretic effect was apparent 



TREATMENT. 325 

and free diaphoresis also occurred. She also stated subsequently that the 
quantity of urine was larger when the pilocarpine was administered every 
third hour than when given at a longer interval. A flaxseed poultice on which 
mustard was dusted was also applied over the kidneys. On June 20th the pulse 
was 96, temperature 100.5°; occasional convulsive attacks occurred, which were 
readily controlled by enemata of hydrate of chloral. On June 30th the symp- 
toms were all better; no more attacks of eclampsia had occurred, and the urine 
was more abundant and less albuminous. The mother remarked that the new 
medicine (pilocarpine) had settled the stomach and increased the urine. The 
patient continued to improve, and on July 4th the record states : " Now takes 
the pilocarpine, gr. 3^2, every six hours ; passes urine freely since yesterday ; has 
not vomited since he began to take the pilocarpine ; pulse 106°, axillary temp. 
99° ; is playful and takes milk freely, nearly three quarts in twenty-four hours, 
with some farinaceous food. Digitalis with potassium acetate is also given in 
occasional doses." July 6th, pulse 92, temp. 99° ; perspires much, and urine 
nearly normal in quantity and character. 

Case 2. — Mary S , aged five years, on Dec. 22, 1882, presented the symp- 
toms of severe nephritis. JHer brother had scarlet fever two weeks previously, 
and she had sore throat at about the same time, but without efflorescence ; pulse 
98, temperature 98.5° ; her urine highly albuminous, and reduced to f^iv in 
twenty-four hours; bowels constipated. Ordered a single dose of 

R. Hydrarg. chlor. mitis, gr. iij ; 

Eesin. podophylli, gr. ^. Misce. 

The muriate of pilocarpine was also ordered, gr. 2^0, but the patient vomited soon 
after taking it. Another dose was retained, and was followed by considerable 
perspiration. Dec. 23d, had one stool from the powder of yesterday. Has taken 
five doses of pilocarpine, but vomited after three of them. The last dose was 
administered at 10 p. m., and the mother says she " sweat fearfully " during the 
night. The patient was kept warm in bed ; stimulating poultices of mustard and 
flaxseed, one to sixteen, were constantly in use over the kidneys, and the pilocar- 
pine was administered three or four times a day. The record for Dec. 26th states : 
" Took the pilocarpine four times since yesterday morning, and each dose is fol- 
lowed by perspiration lasting from one to one and a half hours ; quantity of urine, 
from f^vj to f^viij daily; vomited twice yesterday, not to-day; pulse 104; temp. 
97.75° ; complains of frontal headache ; bowels regular ; has considerable saliva- 
tion. The patient is warm in bed, and the flaxseed and mustard poultice over the 
kidneys is continued." Dec, 28th, specific gravity of urine 1019 : urine still quite 
albuminous and containing blood-corpuscles and granular casts, also crystals of 
oxalate of lime. Dec. 30th, takes gr. 2V pilocarpine twice daily, and occasional 
doses of infusion of digitalis; urine more abundant; its specific gravity 1014, 
slightly albuminous, and containing very few granular casts and blood-corpuscles; 
has lost its smoky appearance ; reaction alkaline ; perspiration slight ; patient 
convalescent. 

In another instance a child of five years, from three to four weeks after 
scarlet fever, was noticed to have anasarca of the face and extremities, with 
scanty and albuminous urine. One-thirty-second of a grain of muriate of 
pilocarpine was administered every six hours without the desired sudorific 
efi"ect. It was then administered every four hours, with an increase of per- 
spiration and urination, so that the nephritic symptoms were relieved and 
the patient apparently out of danger within three or four days. 

In a fourth patient, a girl of three years having scarlatinous nephritis, 
with symptoms very similar to those in the last case, the administration of 
one-twentieth grain doses of pilocarpine in conjunction with the hot-air 
bath was followed by increased perspiration and urination, and progressive 
and rather rapid convalescence. This child had been taking bichloride of 
mercury in one-fiftieth grain doses, prescribed by a homoeopathic physician, 
without appreciable benefit, it having been for the most part vomited. 

Given, as in the above cases, in moderate doses and with sufiicient inter- 
val, pilocarpine has never in my practice had any deleterious efi"ect, and I 



326 SCARLET FEVER. 

regard it as a very important addition to the remedies for the relief of scar- 
latinous nephritis. It is apparently the most useful and important diapho- 
retic for this disease which we possess. 

Cathartics, especially those of a hydragogue nature, are also very bene- 
ficial. Their action is more certain than that of most diaphoretics and diu- 
retics, and their employment is imperatively required in severe or dangerous 
cases in which it is necessary to remove as soon as possible the serum or urea 
which endangers life. Young children or those with delicate stomachs and 
those much enfeebled by the primary disease may take magnesia, either the 
citrate or the calcined. A good cathartic for ordinary cases is a mixture 
of jalap and potassium bitartrate, the pulvis jalapge compositus, consisting 
of one part of jalap and two of cream of tartar. Ten grains of the mixture 
may be given to a child of five years, and repeated according to circumstances. 
Its eff"ect is increased by dissolving a teaspoonful of potassium bitartate in a 
gobletful of water and allowing the patient to drink from it. The following 
cathartic also acts promptly and beneficially in the treatment of scarlatinous 
nephritis : 

R. 01. cinnamomi, gtt. v; 

Magnes. sulphat., .^j ; 

Potass, bitartrat., ^ij. Misce. 
Dose : One teaspoonful repeated from two to four hours until catharsis occurs. 

After the use of laxative agents the kidneys, being less congested on 
account of the diversion that has occurred, often begin to excrete urine more 
freely. But if the patient be anaemic or enfeebled and the symptoms are 
not urgent, it is frequently better to avoid active catharsis, which more or 
less reduces the strength, and employ remedies of a sustaining character, as 
in the following case, which occurred in my practice : A little boy, pallid and 
scrofulous, began to have anasarca after scarlet fever, chiefly in the scrotum, 
accompanied by a moderate degree of ascites. The urine, which was passed 
in nearly the normal quantity, contained albumen, but not in large amount. 
This patient gradually and fully recovered, with no treatment except the use 
of an oil-silk jacket over the kidneys and abdomen to promote diaphoresis, 
and the use of iron. Such a patient, treated by the powerful eliminatives 
which we employ for the more urgent and robust cases, would probably have 
been injured rather than benefited. No treatment can therefore be recom- 
mended in a treatise on scarlatinous nephritis which will be strictly applica- 
ble for all cases. Variations are demanded according to the state of the 
patient and the form and gravity of the disease. 

Diuretics which do not stimulate the kidneys are proper at an early as 
well as late period of the renal malady, and digitalis is the one usually pre- 
scribed. I do not hesitate to order it from the first day in combination with 
the acetate of potassium. One teaspoonful of the infusion may be given 
every third hour to a child of five years. The following formula is for one 
of this age in good general condition : 

R. Potass, acetatis, .^ss ; 

Infus. digitalis, f^vj. Misce. 

The following formulas are recommended by Meigs and Pepper : 

R. Potass, bitart., ^j ; 

Spt. junip. comp., f^ij ; 

Spt. pether. nitros., fjj ; 

Tr. digitalis, lU-^v ; 

Syrupi, f^v ; 

Aquae, fjij. Misce. 

Dose : One teaspoonful every two hours to a child of two to four years. 





TREATMENT. 


R. 


Potass, acetat., 


3J; 




Tr. digitalis, 


f^ss; 




Syr. scillpe, 


f5i-j 




Svr, zingib., 


f^v; 




Aqua?, q. s. 


ad f^iij. 



327 



Misce. 
Dose : A teaspoonful every two or three hours to children two or three years old. 

Local treatment is important. L. Thomas, Romberg, and others recom- 
mend the application of leeches, three or more, over the kidneys. Thomas 
saj-s : " In many cases the abstraction of blood causes immediate and per- 
manent relief ; the fever and the pain in the region of the kidneys cease, the 
secretion of urine becomes augmented, the albuminuria lessens from day to 
day, and the moderate degree of dropsy that has been developed disappears." 
It is only in the more robust children, who have been but little reduced by the 
primary disease, that leeching is, in my opinion, admissible. In the majority 
of cases instead of depletion a poultice slightly irritating, so as to cause red- 
ness of the skin, should be applied over the kidneys, or for older children, 
not likely to be frightened by the process, the dry cups may be applied daily. 
In subacute cases, not attended by any alarming: symptoms, sufficient redness 
may be produced by one of the irritating plasters which the shops contain, 
constantly worn. 

Eclampsia, described in the preceding pages, is produced, as we have seen, 
during the course of scarlet fever by the irritating eifect of the scarlatinous 
poison upon the nervous centres ; but, occurring after the decline of scarlet 
fever, it is ordinarily produced by the retained urea. The same remedies are 
required to control the convulsive movements as when they occur under 
other circumstances. The bromide of potassium should be immediately 
administered in large doses whenever eclamptic symptoms arise. During 
eclampsia a child of three years should take five grains of this agent every 
five to ten minutes till the attack ceases, and then at longer intervals. The 
hydrate of chloral is a more powerful agent, and if the eclampsia be not 
quickly controlled, I commonly employ it per rectum, dissolved in one or two 
teaspoonfuls of water. For a child of three to five years five grains should 
be thrown into the rectum by a small glass or gutta-percha syringe, and 
retained by pressure. Properly administered and retained, it rarely fails to 
control the eclampsia within ten or fifteen minutes. Subsequently, occa- 
sional doses of the bromide should be given to prevent the occurrence of 
eclampsia while the measures described above are being employed to elimi- 
nate the urea. 

Rheumatism, endocarditis, and pericarditis, arising as complications or 
sequelae, require the treatment which is appropriate when they occur under 
other circumstances, but the remedies should not be depressing, as the sys- 
tem is already enfeebled by the primary disease. The rheumatism, if mild, 
usually abates in a few days without medication, and the afi"ected joints 
require only some soothing lotion and support by a bandage. The following 
liniment may be applied upon muslin and covered by cotton wadding : 

R- Acid, carbolici, f^j ; 

Tine, belladonnse, f^j ; 
01. camphorati, fjij. 

If the rheumatism be severe and affect several joints, the sodium salicylate 
should be prescribed, as in the idiopathic disease, with an occasional opiate to 
procure rest. 

Endocarditis and pericarditis require rest in the horizontal position, avoid- 
ance of all excitement, the use of the tincture or infusion of diaitalis or the 



328 ROTHELN. 

tincture of strophantlius to procure a slow and steady action of the heart. 
Three drops of the tincture of digitalis or one to one and a half drops of 
the tincture of strophanthus may be given every four hours to a child of five 
years. The same external measures should be employed as in acute pleu- 
ritis. I prefer the application of a thin poultice of flaxseed containing one- 
sixteenth part of mustard and covered with oiled silk. The cardiac inflam- 
mations, as well as rheumatism, require opiates in sufiicient doses to procure 
rest and sleep. 

Pleuritis, which we have stated is often suppurative, demands the same 
treatment as the idiopathic disease when it occurs in cachectic patients. 



CHAPTER III. 
ROTHELN. 

This disease has also been designated rubella, epidemic roseola, rosalia, 
rubeola notha, and G-erman measles. Some recent writers incline to the 
belief that it occurred in Europe in the eighteenth century, having the 
name rubeola. Thomas states that, according to Formey, 457 died from 
rubeola, 172 from scarlet fever, and 53 from measles in Berlin in the decade 
beginning with 1784 ; but he also states that many who observed these epi- 
demics believed that the rubeola was a species of measles. We infer that 
this was the correct opinion, and that the rubeola of the eighteenth century 
was not the rotheln of the present time, since the latter is almost never fatal, 
except from complications. In Great Britain, from the year 1840 onward, 
various writers, when treating of measles and scarlet fever, make statements 
which lead us to think that they may have sometimes mistaken epidemics of 
rotheln for modified forms of measles or scarlet fever. Perhaps it is not too 
much to claim that the first clear and distinct difl"erentiation of rotheln was 
made in this country. Cases of rotheln occurring in and about Boston were 
described by Dr. Homans, Sr., in 1845, and at a later date — to wit, in 1853 
and 1871 — B. E. Cotting and Mr. D. Howard saw cases, and described them 
in papers read before local societies (Bost. 3Ied. and Surg. Jour., March 15, 
1873). In 1874, Dr. Caleb Green of Homer, Cortland co.. New York, an 
accurate and intelligent observer, also witnessed an epidemic. 

Rotheln was not, however, noticed in American treatises, and it scarcely 
received recognition in America, until an epidemic of it occurred in the New 
York Foundling Asylum and in New York City in 1873-74, which furnished 
the material for a paper published in the Archives of Dermatologi/ in 1874. 
This epidemic began in the latter part of 1873, and attained its maximum in 
March and April, 1874, after which it gradually declined. This, so far as I 
can learn, was the first occurrence of rotheln in this locality. In a general 
practice of more than twenty years, extending over a considerable portion 
of this city, I had previously seen nothing like it, and other older physicians, 
having a large general practice, informed me that they considered it an en- 
tirely new disease with us. Those who believed that they had occasionally 
observed isolated cases of it previously to this epidemic probably referred to 
roseola. 

The first case which I observed occurred in the middle of December, 
1873, in West Seventy-first street, in the northern suburbs of New York. 
A few weeks later cases were so numerous in the more thickly-populated 



BOTHELN. " 329 

section of the city as to attract the attention of many physicians. It was 
evident that a disease had appeared with which we were not familiar, and as 
the eruption occurred in points and small circumscribed patches, it was 
usually designated by the phj^sicians, in want of a more accurate name, epi- 
demic roseola, or was spoken of as a spurious measles. Physicians who 
were familiar with foreign medical literature saw the resemblance between 
these cases and those of rotheln as described by British and continental wri- 
ters, but in certain at least of the foreign cases the duration of the rash was 
said to be seven days (Liveing, London Lancet^ March 14, 1874, and Med. 
Xeics and Lihrari/. May, 1874), whereas in the cases in New York it com- 
monly disappeared by the fourth day. This discrepancy, however, was not 
sufficient to invalidate the belief in the identity of the Xew York disease 
with the foreign rotheln. It was readih' explained by the difference in the 
seasons in which the cases occurred, for Liveing observed his cases in June 
and July, and. as we will see, the greater the external heat the longer is the 
duration of the eruption. 

Between the middle of December, 1873, and May 1, 1874, I had 
observed and treated this malady in eighteen families. Cases occurred in 
three other families living in the same houses with some of those which I 
attended, and, as they were fully and clearly described to me, so that there 
could be no doubt as to their nature, I have included them in my statistics. 
The total number of cases in these twenty-one families was 48. During 
May, when the epidemic was declining. I saw 6 additional cases, occurring 
singly, making a total of 54. Their ages are given in the following- 
table': 

Age. Cases. 

From eight months to one year 2 

" one year to two years 4 

'' two years to five years 16 

'" five years to ten years 23 

" ten years to fifteen years . . . . 3 

" fifteen years to thirty years 6 

Total number of cases 54 

The age of the youngest patient was eight months and that of the oldest 
thirty years : 72 per cent, of the total number were between the ages of two 
and ten years, so that rotheln is pre-eminently a disease of childhood. Indi- 
viduals in and beyond the middle period of life seem to have nearly an 
immunity from it. The age of the oldest patient of whom I was informed 
in the epidemic of 1873 and 1874 was about forty years. On March 25, 
1873, during my attendance in the New York Foundling Asylum, rotheln 
appeared in a boy of four years ; in the following month about thirty more 
cases occurred in this institution, all children, while among the large num- 
ber of female nurses and emplo^'es. who were chiefly between the ages of 
twenty and thirty years, all but three escaped. 

From 1874 to- 1880 rotheln did not prevail in New York, unless now and 
then an isolated or sporadic case, the nature of which was not recognized 
and which was supposed to be roseola. On August 9, 1880, two cases 
appeared in different wards of the New York Foundling Asylum, when it 
was remembered that two weeks previously these children had been exposed 
to a patient in the hospital attached to the institution who had what the phy- 
sician in attendance supposed at the time to be roseola. 

Commencing with these two cases, an epidemic occurred in the asylum, 
mild in t3'pe, affecting only a few at a time, but extending over several 
months, until about sixty inmates, chiefly children, were attacked. Toward 
the close of 1880 rotheln began to appear in the northern part of the city, 



330 BOTHELN. 

in which the asylum is located and over which my practice extends. Its 
maximum prevalence was attained in the latter part of March and April, 
1881, when it particularly attracted the attention of physicians. A large 
proportion of the children attending certain public and private schools were 
attacked. It occurred in seventeen families in my practice! The ages of 
the patients in these families are given in the following table : 

Age. Cases. 

From one to two years 3 

" two to five years 8 

" five to ten years 18 

" ten to fifteen years 11 

There were 2 cases over fifteen years, aged respectively twenty- 
two and forty-two years 2 

Total number of cases 42 

Premonitory Stage. — Premonitory symptoms are in most instances 
absent or so mild as to attract but little attention. It not infrequently hap- 
pened in the New York epidemics that the parents or the teachers in the 
schools were first made aware of the illness of the children by observing the 
eruption. In some instances children were sent from school, not because 
they felt too ill to remain, but on account of the unusual appearance of the 
skin. Sometimes, however, in those old enough to express their sensations a 
premonitory stage of some hours or a day, or even of longer duration, was 
present, consisting of such symptoms as usually occur when one has taken a 
severe cold, as languor, pain in the head, trunk, or limbs. The resident 
physician of the New York Foundling Asylum was so ill with rotheln that 
he was confined to his bed during the first day of the disease. Now and then 
patients experience nausea previously to the eruption and in the first and 
second days of the eruptive stage. In only one instance did I observe grave 
prodromic symptoms. A boy aged eight years was suddenly seized with 
clonic convulsions, and while in a warm bath for the relief of these the rash 
appeared upon those parts of the body which were immersed in water. 

SYMVT0MS.— Tegume7itari/ System. — (a) The Skin. — The eruption com- 
monly commences upon the forehead, around the ears, and along the neck, 
as in measles. Occasionally it may appear upon the back or chest, as in the 
above-mentioned case, in which the hot water accelerated its appearance. 
Commencing above, the efflorescence travels downward, appearing after some 
hours upon the lower part of the trunk and on the legs, resembling in this 
respect the eruption of measles and scarlatina. It occurs upon all parts of 
the integument except the scalp and palmar and plantar surfaces. In the 
majority of the cases which I have seen it gradually faded away, disappear- 
ing by the fourth day, but in children who were kept warm in bed or in 
warm apartments it remained longer than on others. In many instances 
traces of the rash were still visible several days after recovery when the 
patients were heated by exercise or excitement. It reappeared at times, 
though indistinctly, on a girl of thirteen years for three weeks. In most of 
the cases in the New York epidemics the eruption commonly occurred in 
points and circular spots somewhat smaller than those of measles. These 
points and spots were numerous and thickly set, so that, in the aggregate, 
they covered at least half of the surface, while between them the skin pre- 
sented nearly or quite its normal appearance. The general aspect in most 
cases was more like that of measles than that of scarlatina, but in exceptional 
instances the skin between the points and spots had a redness similar to that 
of erythema, and the resemblance was very like the scarlatinous efflorescence. 
Thus, in a boy of three years the eruption so closely resembled the scar- 



SYMPTOMS. 331 

iatinous over the trunk that were it not that the temperature was constantly 
below 100°, and the fever entirely ceased within three or four days, I 
would probably have considered the malady a mild scarlatina. In certain 
patients the eruption, beginning in circumscribed spots, like that of measles, 
becomes in two or three days confluent, so as to resemble that of scarlatina, 
while over other parts the spots remain discrete. This was the character of 
the eruption upon the third and fourth days on the extremities of a little boy 
in the Foundling Asylum. The rash is attended by considerable itching, 
from which, indeed, many patients suffer more than from all other symptoms. 

The eruption disappears on pressure, produces a slight roughness of the 
surface, as ascertained by passing the fingers gently over it, and usually fades 
away without desquamation. Exceptionally, there is a slight branny exfolia- 
tion, and in one of my patients the exfoliation was as great over the abdomen 
as in cases of scarlatina. 

(6) The Mucous Membrane. — In connection with the cutaneous eruption 
a mild inflammation also occurs upon the mucous membrane covering the 
fauces, buccal cavity, and nostrils, and upon reflections of this membrane 
over the eyes and eyelids — i. e. upon the conjunctiva. In certain patients 
this inflammation is scarcely appreciable, but in the majority it arrests atten- 
tion at once. It produces a suffused, reddish, or weak appearance of the 
eyes, with a moderately increased lachr3^mation. On everting the eyelids the 
palpebral conjunctiva is seen to be injected. In certain patients a moderate 
puriform secretion collects at the inner angle of the eyelids. In occasional 
cases the conjunctivitis causes oedema of the lids, usually slight, and likely 
to be overlooked by the physician ; but in three instances which I now recall 
to mind the mothers of the children directed my attention to the swollen 
state of the lids. In one of these, an infant of twenty-three months, the 
tumefaction" was so great, commencing about the time the eruption began to 
fade, that light was totally excluded from the eyes and it was impossible to 
ascertain their condition. The skin over th« eyelids retained nearly its nor- 
mal appearance, and a puriform secretion appeared between the lids. In three 
or four days the oedema of the lids and the hyperemia of the conjunctiva 
rapidly declined. The coryza is in most cases sufficient to cause an unpleas- 
ant sensation in the nostrils and provoke sneezing ; but the flow from the 
nostrils, though present, was in no instance under my observation as abundant 
as in ordinary cases of scarlatina or even of measles. The fauces present an 
injected appearance, and in severe cases there is moderate swelling of the 
tonsils. The same catarrhal hyperaemia is also seen in spots or patches, more 
or less diffused, upon the buccal surfaces. Both the faucial and buccal 
catarrh are less in degree, however, than in cases of rubeola and scarlatina, 
which have an equal intensity of cutaneous eruption : and this fact aids in 
differential diagnosis. 

The Respiratory System. — In both the epidemics which I have witnessed 
the mucous membrane of the larynx, trachea, and bronchial tubes participated 
only slightly in the inflammation which involved the nasal, buccal, and faucial 
surfaces. Many of my patients had no cough, but others had a mild cough, 
lasting a few days, but with normal respiration. It was due apparently to 
a very mild catarrh of the respiratory tract at the time when the nasal 
and conjunctival surfaces were the most affected. It subsided in a few days 
without treatment. In no case do I recollect that there was any hoarseness. 

The Digestive System. — The tongue in rotheln is moist and of normal 
appearance or covered by a slight fur. The appetite may be impaired, but 
is not wanting in uncomplicated cases. The patients sometimes say that it is 
nearly the same as in health ; the thirst is slight, and the bowels are regular. 

Nausea is not infrequent, and vomiting was, in several cases in my prae- 



332 ROTHELN. 

tice, one of the initial symptoms. In certain patients it also occurred on the 
first or second day of the eruption. In others there was no nausea, so far as 
I could learn, either immediately before or during the prevalence of the 
disease. This symptom is less frequent in rotheln than in scarlet fever, but 
is as common apparently as in measles. I have never found albumen in the 
urine, though I have examined that passed by several patients. This secre- 
tion did not appear to be abnormal except as it contained urates, so common 
in febrile states. 

The Pulse and Temperature. — The largest number of accurate daily 
observations relating to the temperature was, I think, that of Dr. Eeid in 
the New York Foundling Asylum during the month of March, 1874. He 
has kindly furnished me with his statistics relating to this symptom, as fol- 
lows : " The number of closely-observed cases in which the temperature was 
taken was 24. In 17 of the cases the temperature ranged from 97° to 99° ; 
in 6 it reached 100°, 100i°, and 100f°; in 1 it reached 103^° on the second 
day of the eruption, but remained so elevated only one day." In certain 
patients Dr. Reid observed what he designates " a tendency to the develop- 
ment of an ephemeral fever." These observations correspond closely with 
those made by myself during the same epidemic. Thus, in 16 cases I found 
the axillary temperature taken each day to be constantly between 98° and 
100°, with a pulse under 110, except in 1 case, in which it numbered 124. 
In certain other patients a more decided rise of temperature from one to 
two or three days occurred, usually in the commencement of the malady. 
Thus, a girl aged three and a half years had a temperature of 101 f° and a 
pulse of 128. In another instance the pulse was 124 and the temperature 
102°. In another, a girl of three and a half years, considerable fever 
occurred without apparent cause on Saturday night, but it abated on 
the subsequent day. She seemed well until the following Tuesday, when 
the fever returned and the eruption appeared. On Thursday the tem- 
perature from 102° to 103° fell to 99J°, and within a day or two she was 
convalescent. In two other patients from two to four days after the disap- 
pearance of the eruption an accession of fever occurred, lasting about one 
day, and attended by pain and distress in the epigastric region, but without 
vomiting or diarrhoea. In one of these the temperature was 103f °, the pulse 
130 per minute. In the other case the temperature and pulse did not seem 
to be under these figures, but were not accurately ascertained. Occasionally 
the fever is due more to complications than to the primary disease. Thus, in 
two of my patients the rise of temperature was mainly attributable to diph- 
theritic inflammation which had attacked the fauces. But while the fever 
in rotheln is ordinarily of short duration, in certain patients temporary 
exacerbations may occur in which the temperature is as high as in scarlet 
fever or measles. 

Complications ; Prognosis. — The only complication which occurred in 
cases in my practice has already been alluded to — to wit, diphtheria, which, 
when prevalent, usually attacks surfaces already inflamed. In the Foundling 
Asylum varicella complicated one case and pneumonia another. In a third 
pneumonia occurred about three days after the disappearance of the eruption. 
The prognosis in uncomplicated cases is always very favorable, and there is 
no liability to sequelae more than in mild catarrhal inflammations of a non- 
specific character. The duration of rotheln is short, not ordinarily extending 
beyond three to five days. 

Nature ; Incubative Period ; Contagiousness. — Is rotheln a distinct 
malady, or one with which we are familiar, but the form and character of 
which are modified by unusual meteorological conditions? Is it roseola 
assuming at certain periods an epidemic character and appearing to be con- 



NATURE, ETC. 333 

tagious ? Or is it at all times infectious, possessing a specific principle, and, 
like other infectious diseases, self-propagating ? Should it in nosological 
classification be placed among the non-contagious and local or among the 
constitutional and infectious maladies ? Let us consider the facts observed 
in the New York epidemics. 

The first cases of rotheln in this city were often designated roseola by the 
physicians called to treat them, since they seemed to resemble more closely 
this disease than any other with which they were familiar. But rotheln 
differs widely from the peculiar form of dermatitis known as roseola. The 
successive occurrence of the eruption over the upper and then the lower 
parts of the body, but covering the whole surface, and the definite duration 
of three to five days, are points of difference. Moreover, roseola would not, 
without so great a change in its character as to become virtually a distinct 
disease, occur in the cool months, without any appreciable dietetic cause, as 
an epidemic over a certain area and for a limited time, affecting whole house- 
holds and sparing other households as well as individuals of a certain age. 
We therefore consider it distinct from roseola. 

Most of the cases of the New York epidemics bore considerable resem- 
blance to measles, both as regards the appearance and duration of the erup- 
tion and the catarrh of the mucous surfaces. Parents often diagnosticated 
measles before the arrival of the physician, and the physician himself, at first 
glance, sometimes made the same diagnosis. But in rotheln the shortness 
and mildness of the stage of invasion, the absence of cough or the presence 
of one trivial and scarcely noticed, appetite good or but slightly impaired — 
in fine, symptoms that are transient or slight — afford a striking contrast to 
the graver symptoms of measles. But the decisive proof that rotheln is not 
a modified measles is found in the fact that one does not prevent the other. 
Of the 48 cases observed by myself prior to May 1st in the epidemic of 
187-i, 19 at least had had measles, and 1 who had rotheln took measles sub- 
sequently. I have already stated that in the New York Foundling Asylum 
rotheln in 1873 and 187-4 closely followed an epidemic of measles. A con- 
siderable number of the children attacked by the former disease had recently 
recovered from the latter. During the epidemic of 1880 and 1881 the same 
fact was observed — namely, that a previous attack of measles as well as 
scarlet fever afforded no protection from rotheln. Dr. Chadbourne, the resi- 
dent physician, writes of the cases in the Foundling Asylum in 1880 and 
1881 : " Eight children had rotheln who had had both scarlet fever and 
measles within six months under my observation, while certain others had 
had these diseases at some previous time." Of the eases observed by myself 
in family practice in the same epidemic, it is stated in my notes that ten had 
had measles. These statistics are sufficient to show that rotheln is a distinct 
disease from measles, however close the kinship. 

That rotheln is not a form of scarlet fever is evident from the fact that 
as regards at least the New York epidemics the rash was in most instances 
quite distinct from the scarlatinous efflorescence, occurring, as we have said, 
in small more or less circular points and patches. Moreover, as we have 
remarked above, there is in rotheln a slight febrile movement and general 
mildness of symptoms which contrast with the high fever and other pro- 
nounced symptoms of scarlatina, or if there be considerable febrile move- 
ment its duration is brief. But the conclusive proof of an essential differ- 
ence between these two diseases is found in the fact already stated in refer- 
ence to measles, that the attack of the one malady does not prevent the 
occurrence of the other. There are, it is true, cases in which it is difficult at 
first to make the differential diagnosis between rotheln and mild measles or 
mild scarlet fever, but when the course of the malady has been closely 



334 ROTHELN. 

observed for three or four days, it will rarely happen, I think, that we will 
be unable to make out its character. 

Those cases of an epidemic which arise when the causes or conditions 
from which it is developed are most strongly operative, and which at this 
time are likely to be typical, obviously afford the best data for studying its 
nature. Such were the 48 cases which I saw in the epidemic of 1873 and 
1874, and the 42 in that of 1880 and 1881. As regards the former epi- 
demic, in thirteen of the twenty-one families embraced in my statistics the 
first cases were children who up to the time of the seizure were attending 
public and private schools, and in certain instances those who were nearly 
simultaneously attacked, living perhaps in streets widely separated, were 
attending the same school. During the epidemic of 1880 and 1881 the 
first patients in thirteen of the eighteen families in which rotheln occurred in 
my practice were school-children between the ages of six and twelve years, 
and in most, if not all, the diff"erent schools which they attended rotheln was 
at the time prevailing as an epidemic, as I ascertained on inquiry. It there- 
fore seemed probable that these children whom I attended had contracted it 
from others in the schools. 

In both the New York epidemics during the time that rotheln was at its 
maximum prevalence, in most of the families containing two or more chil- 
dren the cases were multiple, not occurring simultaneously, but in succes- 
sion, as if the malady were contracted from those first affected. This is what 

we daily witness in the spread of exanthematic fevers. Thus in Mr. E 's 

family a girl attending one of the public schools took rotheln in the middle 
of December, 1873 ; the two remaining children sickened with it one week 
and two weeks later. A niece visiting in the family at the time when the 
first child was sick, but returning home to another street, also had the erup- 
tion on December 27th. Alice II , aged ten years, a frequent visitor at 

Mr. E 's, living in the same street, and several times exposed to his 

children during their illness, also took rotheln about January 4th. West 
Seventy-first street, where these cases occurred, was thinly settled and subur- 
ban, and I could learn of no other cases in the vicinity. A child of Mr. 

P , aged five and a half years, had been in the habit of playing with two 

children two doors away, who became affected with rotheln in the beginning 
of April, 1881. On April 14th he was supposed to have a mild coryza from 
taking cold, as he sneezed often, but in a few hours the efflorescence appeared. 
Four days subsequently, on the 18th, an infant was affected in the same way, 
and thirteen days later another child in the family, aged twelve years. In a 
similar manner rotheln occurred in the families of two brothers living in 
adjoining houses in West Fifty-first street. The first patient was a boy of 
twelve years. It appeared successively in the children of these two families 
until ten had been affected. In a family in West Forty-sixth street the first 
case was a boy attending a school in which rotheln was prevalent. AVithin 
twenty days — namely, between March 31st and April 20th — four other chil- 
dren were attacked in succession. 

These facts and cases seem to demonstrate the contagiousness of rotheln, 
at least during the time in which the conditions are most favorable for its 
development or during the time in which the epidemic influence is most pro- 
nounced. In the declining period of both the New York epidemics the cases 
which I observed occurred for the most part singly, although there was no 
attempt to isolate the patients, so that the contagiousness of the disease 
must be slight. 

Rotheln is, in my opinion, an exanthematic fever feebly contagious. 
It resembles varicella in general mildness of symptoms, in the absence 
of dangerous complications or sequelae, and in the uniformly favorable 



DIAGXOSIS. 335 

prognosis, while its symptoms sliow a resemblance to measles and scar- 
let fever. 

If the above view be correct, rotheln must possess an incubative period 
which, in the cases observed in both epidemics, apparently varied between 
seven, or perhaps less than seven, and twenty-one days. Its incubation, 
therefore, like that of scarlet fever and diphtheria, apparently varies in dif- 
ferent patients. In the cases which came under my notice the incubative 
period, when it could be accurately ascertained, was more frequently about 
two weeks than a longer or shorter period. The resident physician of the 
'New York Foundling Asylum, when the epidemic was prevailing in that 
institution, returned to his home in the State of Maine to a locality where 
rotheln was unknown. Fourteen days from the date of his departure he was 
himself affected with the disease in its typical form. No other case occurred 
at his home, where probably the atmospheric conditions were unfavorable. 

Minnie B , attending a school in which there were many cases, had the 

rash on April 5th. On the 23d of the same month, eighteen days afterward, 
it appeared upon the servant who was frequently in Minnie's room. Eliza- 
beth C , attending a school in which rotheln was prevailing, had the 

eruption on April 17th. It commenced upon her sister thirteen days, and 
upon her mother fourteen days, subsequently. 

Other cases might be cited of an apparently shorter as well as longer 
incubative period. The following note from Dr. Chadbourne of the New 
York Foundling Asylum, bearing upon this subject, is interesting: "I am 
led to believe from my observations that the period of incubation was, in the 
majority of cases, from twelve to fifteen days. The disease has been very 
feebly contagious. In some cases one child would have rotheln, while the 
other, nursed by the same woman, escaped. In two instances women had 
the disease, and though each suckled two infants, the latter escaped." 
Osborn states that enlargement of the small glands at the edge of the hair 
on the postero-lateral sides of the neck has been present in all the cases 
which he has observed, and he therefore considers it an important diagnostic 
sign ( Wcekl?/ Med. Rev.. Dec. 24, 1887). Several other writers have also 
observed this glandular enlargement, and some have stated that it occasion- 
ally precedes the efflorescence. Swelling of the lymphatic glands in other 
parts of the system has also been recorded by different observers, and it 
rarely goes on to suppuration. It usually subsides with the disappearance 
of the rash, but Golson has observed the occurrence of abscesses in the site 
of the submaxillar}' lymphatic glands. Curtman has also observed the for- 
mation of abscesses in various parts of the body. 

Complications. — Recent writers have recorded a considerable number 
of complications and sequelae, the more important of which we will briefly 
enumerate as follows, but the occurrence of some of them was a coincidence : 
severe bronchitis, pneumonia, pleurisy, enteritis, entero-colitis, colitis, icterus, 
stomatitis, rheumatism, meningitis, abscesses, miliaria, pemphigus, erysipelas, 
oedema, enlargement of the thyroid, otorrhoea, earache, and keratitis. Some 
of these complications are such as frequently occur in measles, to which, as 
we have seen, rotheln bears considerable resemblance. 

Diagnosis. — Eotheln might readily be mistaken for roseola if only a few 
and isolated cases occur, but the longer continuance of the eruption, the 
catarrhal symptoms, though slight, and in most instances the evidence of 
contagion, enable us to make the diagnosis. From measles this disease is 
distinguished by the absence of, or slight and transient character of, the pro- 
dromal stage. The fever with evening exacerbations, the cough, and pro- 
nounced catarrhal symptoms, which precede the rash in measles three or four 
days, do not occur in rotheln. The diagnosis from mild scarlet fever in the 



336 VARIOLA— VABJOLOW. 

commencement of an epidemic, when only a few cases are observed, may be 
difficult, but no epidemics of scarlet fever occur in which the type remains 
so mild as in rotheln. The shorter duration of the rash, the absence of the 
initial vomiting and of the strawberry tongue, the usual roseolar rather than 
erythematous character of the rash, the mildness, sometimes scarcely appre- 
ciable, of the stomatitis and pharyngitis, the slight indisposition, so that the 
child, if it followed its inclination, would not be under restraint, and the 
absence, with few exceptions, of complications and sequelas, usually render 
the diagnosis from scarlet fever clear and unmistakable. 

Prognosis. — Death does not occur except from some complication or 
intercurrent disease. When Forney stated that in Berlin during the decade 
ending with 1794, 457 died from rubeola, 172 from scarlet fever, and 53 
from measles, he could not by the term '^ rubeola " have referred to rotheln, 
as some have supposed, or the nature of the disease has totally changed. 
Moreover, in the literature of rotheln the assigned causes of death have been, 
in my opinion, in some instances, concurrent or accidental maladies which did 
not result from this disease. 

Treatment. — In the majority of cases the medicinal treatment should 
be of the mildest kind or none at all. As death has occurred from bronchitis 
and pneumonia supervening upon rotheln, the patient should remain in a 
room of equable temperature, and not be exposed to currents of air. Any 
local ailment which may arise or any intercurrent disease should of course 
be promptly treated, since death may occur from them, while the primary 
disease is not fatal and is even trivial. 



CHAPTER IV. 

VARIOLA— VAKIOLOID. 

Variola, or smallpox, is a specific febrile affection, accompanied by a 
vesiculo-pustular eruption upon the skin. Since the discovery of the protec- 
tive power of vaccination it has been shorn of much of its terror, but it is still 
the most loathsome and most dreaded of all the fevers. Two forms of this 
disease are recognized, depending on the fact whether there have been pre- 
vious vaccination. If the patient have been vaccinated at some period in 
his life, the disease, which is rendered milder in consequence, is designated 
varioloid. If there have been no vaccination, it is called variola or small- 
pox. Both forms are identical in nature, the one communicating the other; 
they differ only in gravity. 

From accounts still extant — which, however, are vague — this disease 
appears to have prevailed at a remote period in China and Hindostan. It 
was carried across the Asiatic continent by caravans engaged in the silk- 
trade, reaching Europe in the sixth century. Its extension to countries 
previously free from it has been mainly through commerce and invading 
armies. It is stated that it reached England in the thirteenth century and 
Germany and Sweden in the fifteenth century. It was introduced into Mex- 
ico by the invading army of Cortez, where for years afterward heaps of skele- 
tons of those who had perished by it were found in shaded localities. 

Etiology. — Different microscopists have observed a microbe in the vario- 
lous eruption, designated the micrococcus tetragonus. It bears some resem- 
blance to the sarcina ventriculi, having the appearance of a group of four. 



STAGE OF INVASION. 337 

It is readily cultivated in different media, and has an orange-yellow colot. 
Dr. A. Marotta has performed experiments with this microbe which seem to 
have the conditions of scientific exactness, and render it highly probable that 
it is the specific principle of smallpox. He states that he inoculated calves 
with this microbe of the seventh generation of cultivation, and produced in 
them an eruption apparently identical with that of vaccinia, but inoculations 
of dogs and guinea-pigs were without result.^ These experiments of Marotta 
require verification. Guthmann has found the staphylococcus pyogenes and 
micrococcus albus in the variolous lymph, but they are often present in mal- 
adies entirely distinct from variola, and are therefore not believed to sustain 
a causal relation to the latter. Although pathologists do not doubt the 
microbic origin of variola, the microbe which causes it has not yet been 
clearly ascertained. ^ 

Smallpox presents four stages : the initial, or that of invasion ; the erup- 
tive ; that of desiccation ; and, lastly, that of desquamation. It is termed 
discrete when the pustules remain separated from each other ; confluent 
when they unite. This division is made according to the character of the 
eruption upon the face and hands. There are parts of the surface, as the 
abdomen, where the pustules are always discrete, even in the confluent form. 

Incubative Period. — During the last half of the last century inocula- 
tion with variolous matter was extensively practised in Grreat Britain and on 
the Continent, as it was found that smallpox thus communicated was milder 
than when received by infection. This operation enabled physicians to deter- 
mine the period of incubation, which was found to be from eight to eleven 
days. When variola is communicated through the air the incubative period 
is somewhat longer — to wit, from twelve to fourteen days. 

Stage or Invasion. — Smallpox begins abruptly with chilliness. In 
children of an advanced age there is often, as in the adult, a distinct chill. 
This is followed by fever and such symptoms as usually accompany a high 
temperature — to wit, lassitude, anorexia, ajad thirst. In addition, certain 
symptoms arise which, though not peculiar to smallpox, are so marked in 
the commencement of this disease that they possess considerable diagnostic 
value. These symptoms, which pertain to the nervous system and occur in 
the initial stage of varioloid as well as variola, are severe frontal headache, 
pain in the small of the back, and great drowsiness, sometimes with delirium. 
In many children convulsions occur, preceded and followed by a degree of 
stupor which is almost as profound as coma. Trousseau suggests the name 
rachialgia for the pain in the back, since he believes that it is located in or 
around the spinal cord. This belief is based on the fact which he, as well as 
other observers has noticed that there is sometimes in connection with this 
symptom an incomplete paraplegia, indicated by numbness of the legs or even 
inability to use them, and sometimes more or less paralysis of the bladder. 
These paraplegic symptoms pass off in a few days. Vomiting is also a com- 
mon symptom in this stage, and one also of diagnostic value. It occurs at 
short intervals for, twenty-four to thirty-six hours. The same symptom is 
common in scarlet fever, and not infrequent in measles, but in both these 
maladies irritability of stomach is much less persistent than in smallpox ; 
vomiting does not occur in normal rubeolous and scarlatinous cases more than 
once or twice. 

The tongue is covered with a moist fur. If the disease is to be discrete, 
constipation is commonly present in the stage of invasion ; if confluent, 
diarrhoea is a common symptom, continuing till the fourth or fifth day, or 
even longer. Roseola or erythema sometimes occurs in this stage, and this 
may lead to error of diagnosis, the disease being mistaken for one of these 

^ Dr. A, Marotta : Bevista Clinica e Therapeutica, ]S"ov. and Dec, 1886. 
22 



338 VARIOLA— VARIOLOID. 

cutaneous aifections or even for scarlet fever. The symptoms in the stage 
of invasion are usually more violent in confluent than in discrete variola, but 
there are exceptions. 

Stage of Eruption. — The eruption commences about the third day, earl- 
ier in some cases, later in others. The average duration, therefore, of the first 
stage is somewhat shorter than in measles, but considerably longer than in 
scarlet fever. Sydenham has stated — and observations show the truth of the 
remark — that the shorter the first stage the more severe the disease will 
prove to be ; and, conversely, the longer the period the milder will be its 
form. Therefore, if the eruption begin on the second day, it will, as a rule, 
be confluent; if not till the fifth or sixth day, it will be scanty and the dis- 
ease light. 

The eruption commences in minute red spots, somewhat like those of 
lichen, which gradually enlarge. It is first observed around the lips and 
upon the neck, then upon the face, scalp, upper part of chest, arms, and 
finally upon the lower part of the chest, the abdomen, and legs. It is some- 
times, especially in young children, first observed in the folds of the skin, as 
about the genitals or in the groin. If the cuticle be irritated, as by a sina- 
pism, the eruption often appears first upon this part of the surface and in 
greater abundance than elsewhere. Commencing in a minute reddish point, 
as stated above, it rapidly enlarges, and soon its central part begins to be 
indurated and raised. It feels round and hard to the finger, is tender, and 
its diameter does not ordinarily exceed two lines. This is the papular stage. 
The papulae increase and become more elevated, and in twenty-four to forty- 
eight hours from the commencement of the eruptive stage they become vesic- 
ular. On the fifth day of the eruption, or eighth of the disease, the vesicle 
has attained its full size. Its diameter is then about one-fourth of an inch 
and its elevation is two or three lines. Its base is circular and indurated, 
and it is surrounded by a narrow zone of inflammation, indicated by redness 
and tenderness of the skin. The pock commonly, as it passes from the papu- 
lar to the vesicular stage, loses its acuminate form, and becomes depressed in 
the centre, but in most cases mixed with the umbilicated vesicles are some 
which remain acuminate. 

In proportion as the eruption becomes developed in discrete variola and in 
varioloid, the symptoms which accompanied the stage of invasion abate ; the 
fever, headache, pain in the back, and thirst cease, and the appetite returns. 
In the confluent form the fever continues with little abatement. 

Simultaneously with the eruption upon the skin an eruption also occurs 
upon the buccal and faucial surfaces, and often upon that of the air-passages. 
It occurs sometimes, also, upon the conjunctiva, producing dangerous oph- 
thalmia, and even ulceration with loss of sight, and upon the mucous sur- 
face of the genital organs. The form which it presents upon mucous sur- 
faces is somewhat different from that upon the skin. There is at first a 
deposit of fibrin, producing a small, round, grayish spot at the point of 
eruption — firm, slightly elevated, and covered, if not by the entire mucous 
membrane, at least by its epithelial layer. Ulceration soon occurs, as in 
ulcerous stomatitis, and if the patient live the reparative process succeeds, 
as in simple ulcers. The eruption upon mucous surfaces increases consider- 
ably the suffering of the patient, in consequence of the tenderness of the 
ulcers ; and if its seat be the surface of the larynx or trachea, it may be the 
immediate cause of death, especially in young children, by obstructing 
respiration. 

The cutaneous eruption has been traced to the vesicular stage. On or 
about the fifth day of the eruptive period, or eighth of smallpox, the ves- 
icles gradually change their character, their contents becoming thicker and 



STAGE OF DESQUAMATION. 339 

turbid. At the same time they increase still more in size and the central 
depression disappears. This is designated the stage of maturation or of 
suppuration, though it is known that the turbidity is due chiefly to another 
substance than pus. The pock, having undergone these changes, is termed 
the pustule. 

In discrete variola and in varioloid the fever returns during the pustular 
stage, or if the form of the disease be confluent and the fever have con- 
tinued, it now becomes more intense. The return of fever or its increase 
is denoted by increased frequency of pulse, elevation of temperature, dry- 
ness of skin, anorexia, and thirst. A tendency to constipation remains 
throughout in varioloid and discrete variola ; in the confluent form diarrhoea 
more frequently occurs, which, if it continue, is an unfavorable prognostic 
sign. 

Other changes occur. The pustules increase somewhat in size and become 
more globular. Some of them, when most distended, break through friction 
of the clothes or scratching of the child, and their contents, escaping, add to 
the loathsomeness of the disease. There is in the pustular stage more or less 
redness of the surface between the eruptions, and, except in the mildest 
cases, tumefaction from subcutaneous infiltration occurs. In the confluent 
form at this period the features are often so swollen that the friends would 
not recognize the patient. The eyelids may be so oedematous that the eyes 
are for a time concealed from view. This oedema of the surface is not alto- 
gether absent in the vesicular stage, but it increases during the time of 
maturation, after which it subsides. 

Stage of Desiccation. — This immediately succeeds the full develop- 
ment of the pustules. The liquid portion of the contents of the pustules 
which are broken evaporates, leaving a crust. If there be no rupture, the 
liquid is absorbed and a scab results, whicb, though smaller, preserves in a 
measure the form of the pustule. While the pustule desiccates the sur- 
rounding inflammation rapidly abates. The crusts occur first upon the face, 
and on other parts in the order in which the eruption appeared. The odor 
from the patient at this time is peculiar. In the confluent form especially it 
is very offensive, and can be noticed at a distance from the bedside. Eilliet 
and Barthez call it nauseous and fetid. As desiccation progresses the symp- 
toms, local and general, abate. The pulse and temperature, if the case be 
favorable, return to the normal ; the cough, hoarseness, and thirst disappear, 
while the appetite returns ; the sleep is more tranquil, and the functions gen- 
erally are more regularly performed. 

The last stage is that of desquamation ; it commences between the 
eleventh and sixteenth days. The scabs, which present a dark or brownish 
appearance, are successively detached. This period lasts several days ; some- 
times two or three weeks even elapse before all the crusts separate. In the 
mean time, the patient gradually recovers his health and former strength. 
After the fall of the crust the cicatrix underneath presents a reddish appear- 
ance. The color gradually fades, and there remains an irregular depression, 
or pit, of a lighter color than the surrounding surface, and, if there have 
been a full development of the eruption, disfiguring the patient for life. 

Such is the clinical history of variola when it is favorable and its course 
is regular. The disease is sometimes irregular. In rare instances the erup- 
tion occurs almost at the commencement of the attack. The form is then 
likely to be confluent. There are irregularities also in consequence of 
diarrhoea, hemorrhages, or other complications. I have known the eruption 
appear first on the limbs, and last on the trunk and face, and the appearance 
of the eruption is not always the same. In the anaemic and feeble child it 
often presents a pale color, with some induration at its base, but without the 



340 VARIOLA— VAEIOLOIB. 

red areola around it or with this quite indistinct. In rare instances the ves- 
icles have a reddish color, their contents being tinged with blood. This form 
of variola is designated hemorrhagic. It indicates a profoundly altered state 
of the blood. The eruption in this form is of small size, and if the pock is 
broken, blood oozes from it. 

I have met one case, perhaps two, of malignant hemorrhagic smallpox, 
as described by Hebra, among the rare forms of this malady. The second 
case died so soon that we were undecided whether he had smallpox or scar- 
latina. A man aged thirty-six years, previously healthy, became suddenly 
and severely sick in June, 1881, with fever, intense headache and backache, 
great depression of the vital powers, sleeplessness, and a sensation of sinking 
or depression in the epigastrium. He had a marked foreboding of coming 
evil, and begged almost constantly for relief. Within forty-eight hours a 
heavy and continuous dusky scarlatiniform eruption covered the whole sur- 
face, except below the knees, disappearing on pressure ; fauces at first but 
moderately injected. On the following day, the third of his sickness, with a 
temperature of 104.5°, the efflorescence became a dark red, numerous small 
extravasations of blood had occurred under the skin, the urine contained 
blood, and finally it seemed to consist almost entirely of dark blood ; a large 
eff'usion of blood under the entire conjunctiva of either eye prevented closure 
of the eyelids, and probably hemorrhages had occurred within the eyes, as 
the sight was nearly lost. Death took place on the following day. In Hebra's 
article on smallpox is the description of precisely such cases, but the death of 
my patient was too early for exact diagnosis. 

Varioloid. — The course of varioloid is similar to that of variola, but it 
is somewhat shorter. It commences with rigors, followed by fever, head- 
ache, pain in the back, vomiting, drowsiness, and sometimes delirium, or 
even convulsions. The symptoms in the stage of invasion are, indeed, the 
same in character, and often nearly as severe as in variola. With the initial 
symptoms there is also sometimes a scarlatiniform eruption, so that the 
disease may at first be mistaken for scarlatina. On the third or fourth day 
the variolous eruption commences. The number of pocks is commonly few, 
often not more than twelve to twenty. In the mildest form of varioloid, if 
the physician be not summoned in the stage of invasion, he may not be called 
at all, so that the patient passes through the disease in ignorance of its nature. 
The true character of the malady is not ascertained till others are affected 
either with variola or varioloid. 

The eruption pursues a more rapid course in varioloid than in the unmod- 
ified disease. By the fifth or sixth day the pustules are fully developed, 
though often smaller and less likely to be ruptured than in variola. Often 
in varioloid the eruption aborts. It remains papular two or three days, and 
then declines, or it may reach the vesicular stage and decline without pustu- 
lation. 

The constitutional symptoms in varioloid abate with the commencement 
of the eruptive stage. The secondary fever is slight or absent. 

Such is the usual mild course of varioloid, but not always. If several 
years have elapsed since the vaccination, its protective power is greatly 
impaired, and varioloid may then exhibit as severe a form as ordinary small- 
pox. In some instances it is fatal. 

The term varioloid is, as has been stated, applied to cases of variolous 
disease if there have been previous vaccination. It is also applied by writers 
to second attacks, whether the first occurred from infection or from variolous 
inoculation, but such cases are rare. 

Mode of Death. — Death in smallpox occurs in several different ways. 
The most fatal period is the pustular. Feeble children not infrequently die 



COMPLICATIONS. 341 

from exhaustion at or about the time that the pustules attain their greatest sizel 
The eruption appears and becomes developed as usual, but there are evi- 
dences of weakness in the patient, and suddenly the progress of the vesicle 
or pustule ceases. It begins to subside and its walls shrivel. There is evi- 
dently absorption, in part, of the liquid contents. These phenomena are of 
the gravest character. Death is the common result, and within twentj^-four 
hours. ,In other cases death occurs from apnoea. The pock, increasing in 
size in the larynx and trachea, obstructs inspiration, or there may be the 
formation of a pseudo-membrane, as in true croup. This is not an unusual 
mode of death in young children, in whom the calibre of the larynx and 
trachea is small. Sometimes convulsions and coma occur in the last hours 
of life. In other cases the stage of desquamation is reached, but convales- 
cence does not occur-. The patient each day becomes more anaemic and 
feeble, and finally death results from failure of the vital powers. Again, 
after smallpox has run its course purpura haemorrhagica may be developed. 
Hemorrhages occur from the gums, throat, nostrils. Blood is vomited, and 
evacuated in the stools. I have known death to occur in all these ways, but 
that from purpura is least frequent. Sometimes, as in scarlet fever, death 
occurs suddenly and unexpectedly in confluent, and even in discrete, variola, 
when the previous symptoms had apparently been favorable. The patient is 
overpowered by the intensity of the virus. 

Anatomical Characters. — In those who have died of variola without 
inflammatory or other conxplication the heart-clots have been found small, 
dark, and soft. The blood is dark and thin. The vessels of the brain and 
its membranes are injected, so that numerous red points appear on the cut 
surface of this organ. The vessels of the lungs and the abdominal organs 
are congested, while the muscles present a deep-red color. The variolous 
eruption penetrates more deeply than that of any other exanthematic fever. 
It has been stated elsewhere that it occurs not only on the skin, but often 
on the surface of the mouth, fauces, and air-passages. The mucous mem- 
brane in these situations is frequently also the seat of catarrhal inflammation, 
being thickened and softened, and in some parts, as the larynx, a pseudo- 
membrane is occasionally produced, as in croup. 

The eruption very seldom, perhaps never, appears upon the gastro-intes- 
tinal surface, but the solitary follicles and patches of Peyer are often 
enlarged, as in some other zymotic aff"ections. The liver, spleen, and kidneys 
are commonly congested in those who have died of variola. The spleen 
especially is increased in volume and softened ; the kidneys are enlarged, as 
from commencing nephritis, and sometimes softened. 

The minute structure of the pock is described by Eilliet and Barthez 
and others. The vesicle is multilocular, consisting of at least five or six com- 
partments with distinct partitions. Its centre is united by fibrous bands to 
the derm beneath, which union gives rise to the umbilicated appearance. 
The giving way of these minute bands in the pustular stage occurs when 
the form changes frjom the umbilicated to the convex. In the pustular stage 
also, according to some, a fibrous formation occurs within the pustule ; 
according to others, this substance is of the nature of the epidermis, pre- 
senting the appearance of the cuticle when macerated. Mixed with this 
epidermic or fibrinous formation are pus-cells. 

Complications. — There are several diff'erent complications of variola. 
One is salivation. This is common in the adult, but rare in the child. 
When it occurs in the child it is slight, commencing with or about the time 
of the eruption, and disappearing in from one to four or five days. Oph- 
thalmia is another complication. Simple conjunctivitis, often quite intense, 
may occur in consequence of pustules developed under the lids. This 



342 VARIOLA— VARIOLOID. 

inflammation subsides without injury to the eye as the primary disease 
abates. A more serious inflammation occurs at an advanced stage of variola, 
commencing in or near the desquamative period. This produces more or 
less chemosis, and sometimes opacity or ulceration of the cornea. A similar 
inflammation may occur in the ear, giving rise to otorrhoea, and even, in some 
patients, to rupture of the drum of the ear. Abscesses in the subcutaneous 
connective tissue have been occasionally observed, especially in the confluent 
form. Subcutaneous infiltration and feebleness of constitution favor their 
occurrence. Suppuration within the joints is a somewhat rare complication 
or sequel, rendering convalescence protracted, if, indeed, the case be not 
fatal. 

M. Beraud has published a memoir to show that orchitis in the male and 
ovaritis in the female may complicate variola. These inflammations are 
believed to be accompanied by a small and imperfect variolous eruption 
upon the tunica vaginalis and the peritoneal covering of the ovary. Trous- 
seau states that he has often met this complication in the male since his 
attention was called to it. It is mild, and subsides with the disappearance 
of the eruption. Laryngitis, simple or diphtheritic, bronchitis, pneumonia, 
pharyngitis, purpuric hemorrhages, gangrene of the mouth or other parts, 
oedema pulmonum, and oedema glottidis are occasional complications, some 
of which are frequent, others rare. 

Prognosis. — This depends on the age, vigor of system, form of the 
disease, and the presence or absence of complications. The younger the 
child the greater the danger. Trousseau says : " Confluent variola, and even 
discrete variola, are almost always fatal in individuals less than two years 
old." Above the age of three or four years discrete variola usually ends 
favorably, but the confluent form is still, as a rule, fatal. Varioloid in the 
child is a mild disease, terminating favorably in a large proportion of cases. 
It is milder at this age than in the adult, on account of the more recent 
period of vaccination. If varioloid be severe and the eruption abundant 
in a child who has been vaccinated, it is probable that the vaccination was 
spurious. 

It is not necessary, from what has been said, to specify the favorable 
prognostic signs. The unfavorable prognostics are — great violence of the 
initial symptoms ; early appearance of the eruption ; an abundant eruption, 
especially if pale and without swelling of the surface ; rapid decline of the 
eruption in the vesicular or pustular stage ; hemorrhagic eruption or hemor- 
rhages from the surfaces ; fever continuing after the appearance of the erup- 
tion ; diarrhoea persisting beyond the third or fourth day ; delirium or great 
drowsiness ; a frequent and feeble pulse ; and, finally, obstructed respiration 
— if slow, indicating a pseudo-membrane or variolous eruption in the larynx 
or trachea ; if rapid, indicating bronchitis or pneumonia. 

Diagnosis. — The diagnosis cannot be made with certainty prior to the 
eruptive stage. If, however, smallpox be prevalent, if the patient have not 
been vaccinated, and the symptoms which pertain to the period of invasion 
be present, as headache, pain in small of back, repeated vomiting, drowsiness, 
and perhaps convulsions, there is ground for the gravest suspicion. If in 
addition to these symptoms reddish points begin to appear on the second or 
third day, the diagnosis may be made with confidence. At this early period, 
even before there is any distinct cutaneous eruption, ash-colored spots may 
sometimes be observed on the buccal or faucial surface, the commencement 
of the variolous eruption ; these possess considerable diagnostic value. 

The scarlatiniform efflorescence in the first stage of variola sometimes 
leads to the belief that the disease is scarlet fever. The absence of the 
pharyngitis and the appearance of the variolous eruption soon after the 



TREATMENT. 343 

efflorescence correct the diagnosis. Smallpox lias, in the beginning of the 
eruptive period, sometimes been mistaken for measles. The points involved 
in the differential diagnosis have been presented in treating of that disease. 
After the development of the eruption it may be mistaken for varicella. The 
eruption of varicella is, however, preceded by symptoms which are milder 
and of shorter duration, and its appearance is different. It is irregular, 
instead of round, is not umbilicated, and it does not have the round, inflamed, 
and indurated base which characterizes the variolous eruption. The eruption 
of ecthyma is sometimes umbilicated, but the symptoms of ecthyma and variola 
and the progress of the eruptions in the two diseases are very different. 

Treatment. — Smallpox, like the other essential fevers, is self-limited, 
and therefore the constitutional treatment should be sustaining and pal- 
liative. In the first stages of the disease the diet should be simple ; gentle 
laxatives and refrigerant drinks are required if there be much febrile excite- 
ment. Lemonade is a grateful drink, and maybe given in moderate quantity. 
Spiritus mindereri in carbonic-acid water may be allowed. As the disease 
advances more nutritious food should be recommended, and in severe cases 
carbonate of ammonium, and even alcoholic stimulants, are required. 

As confluent smallpox is nearly always, and the discrete form often, fatal 
in infancy, the physician should carefully watch the progress of the case in 
the infant. By judicious treatment some in this period of life may be saved 
who otherwise would perish. In the infant depressing measures should be 
avoided. A laxative may be given at first if there be much fever and the 
bowels are constipated ; but the diet should be nutritious, and many soon 
require tonics and stimulants. If the pulse become more frequent and 
feeble, or if, with frequency of the pulse, the face and extremities become 
cool, or in the vesicular or pustular stage the eruption suddenly subside, 
alcoholic stimulants must be immediately employed or the patient dies. 

Such is an outline of the constitutional treatment required in smallpox. 
Sydenham inculcated a mode of treatment which experience has shown to be 
injurious in infancy and childhood. He had observed that the severity of the 
disease was ordinarily proportionate to the amount of eruption, and concluded 
from this fact that measures which retarded the development of the eruption 
were salutary : cold drinks, a cold apartment, scanty covering of the body, 
cathartics that caused derivation of the blood from the surface, even some- 
times the abstraction of blood, were considered, according to Sydenham's 
theory, to be useful as means of preventing full development of the 
eruption. 

Sydenham's treatment, however appropriate it might sometimes be in case 
of robust adults, is unsuitable for children, because they do not, as a rule, 
tolerate in this disease measures which reduce the strength. Moreover, 
smallpox is rendered more dangerous by what Rilliet and Barthez designate 
perturbating treatment — treatment which renders it abnormal. The regular 
appearance and development of the eruption are requisite in order that the 
case may progress favorably. On the other hand, the opposite plan of treat- 
ment, which families, if left to themselves, frequently adopt — to wit, the 
employment of measures to promote perspiration, as hot drinks and confine- 
ment in a heated room — is also injurious. 

The patient should be kept in a temperature such as he has been accus- 
tomed to and such as is agreeable to him — a temperature at QQ° to 70° ; his 
diet should be simple and nutritious; laxative medicine should only be given 
to procure the natural evacuations. In smallpox, as in all infectious dis- 
eases, free ventilation of the apartment is required. The room should be 
dark, for a strong light perhaps increases the pitting. 

While the general eruption should not. as a rule, be interfered with, it is 



344 VARIOLA— VARIOLOID. 

proper to endeavor to diminish, so far as possible, the size of the pocks on 
parts exposed to view, so as to prevent disfigurement. Professor Flint, in his 
Treatise on the Practice of Medicine^ has published an excellent summary of 
the various measures which have been recommended for accomplishing this 
end. First : The opening and breaking up of the vesicle by means of a fine 
needle. This is tedious practice in confluent variola, but it can i;eadily be 
performed in the discrete form — at least as regards the vesicles upon the face. 
This treatment was proposed by Kayer, and it is recommended by many who 
have tried it. Secondly : After the evacuation of the liquid the cauteriza- 
tion of the vesicle by a pointed stick of nitrate of silver. Rilliet and Bar- 
thez say, in reference to this mode of treatment, " Individual cauterization 
of the pustules is, on the other hand, an almost infallible means of causing 
them to abort. To be successful, it is necessary to penetrate into the interior 
of the pustule with a pointed crayon of nitrate of silver in order to cauterize 
the derm. .... It is only the first or second day of the eruption that it 
(cauterization) has certain success ; nevertheless, we have often seen it suc- 
ceed the third or the fourth day, or even the fifth." Thirdly : The appli- 
cation of tincture of iodine once or twice daily over the eruption when in 
the papular stage. Some writers who have employed iodine state that it 
does not prevent pitting, but diminishes it. Its favorable efi"ects are pro- 
duced by coagulating the contents of the papule. Fourthly : The exclusion 
of light and air by means of a plaster. A mixture containing tannate of 
iron has been employed for this purpose in one of our hospitals. This 
produces a black mask. Light and air may also be excluded by smearing 
the face with sweet oil and dusting twice daily upon the oiled surface a 
powder containing equal parts of subnitrate of bismuth and prepared chalk. 
Fifthly . The application of mild mercurial ointment upon the face or other 
parts of the surface where it is desirable to render the eruption abortive. 
This mode of treatment does diminish the size of the vesicles and the pitting, 
but I should not recommend it for children. I have known in the adult 
severe mercurialization from its employment for four or five days, and, though 
young children do not exhibit so readily the effects of mercury, the use of 
the ointment, unless for a very limited period, increases, in my opinion, their 
feebleness and diminishes the chance of their recovery. Calamine made into 
a paste with sweet oil is said to be equally effectual with mercurial ointment, 
and it produces no constitutional effect. Its effect is obviously similar to that 
of the bismuth and chalk employed with sweet oil as stated above. Also, I 
have employed pulverized charcoal made into a thin paste with sweet oil or 
glycerin, and applied daily or twice daily to the face. It effectually excludes 
the light, and the result appeared to be good as regards pitting, but it is a 
disagreeable application. Curschmann recommends as preferable to any of 
these methods the use of iced compresses to the face and hands. The pain, 
redness, and swelling are diminished by their use, but without change in the 
copiousness of the eruption (Ziemssen's Encyclojj.y If fissures or excor- 
iations occur, an application may be made of oxide or carbonate of zinc in 
glycerin, one drachm to the ounce. 

Dr. Tomkyns of the Fever Hospital, Manchester, England, states that he 
has used with good results the following mixture, applied from time to time 
over the surface : 

B- Glycerini, ^ss; 

Tine, iodini, .^ij ; 

Sol. amyli, Oss. Misce. 

The intense itching and the fetor are, according to my observations, best 
relieved by frequent bathing with the following wash : 



VACCINIA. 345 

B. Acid i carbolic, .^j ; 

Tine, camphor., ^ij ; 

Aqiue, Oj. Misce. 



Shake bottle before using. 



The prevention of smallpox, so far as practicable, is one of the important 
incidental duties of the physician. Isolation of the patient and precautious 
in reference to his clothes and bedding are imperatively required, so great is 
the contagiousness of this disease. The only certain means of prevention is 
vaccination, and providentially the incubative period of the vaccine disease 
is less than that of variola. Therefore, smallpox may be prevented after the 
virus is received in the system by timely and successful vaccination. Vac- 
cination, at any period between the time of exposure and the commencement 
of the symptoms of invasion, will either prevent the occurrence of smallpox 
or modify it. If the symptoms of invasion have ah^eady commenced, it is 
uncertain whether it produces any modifying effect. 

Variola is so very contagious that there is danger that the physician and 
attendants may communicate it through their persons or clothing. The virus 
adheres tenaciously to objects, and may be conveyed by them long distances. 
Therefore the room occupied by the patient should contain no unnecessary 
articles, as books or writing material, and the physician attending a case 
should bathe and change his clothing before going elsewhere. A disinfectant 
should also be constantly used in the room, as the following, which I have 
recommended in the treatment of diphtheria and scarlet fever : 

R. 01. eucalypti, 

Acidi carbolic, da. ,^j ; 
Spts. terebinth., ^viij. Misce. 

Two teaspoonfuls in a quart of water, placed in a tin vessel, shallow and with broad 
surface, and maintained in a state of constant simmering. 



CHAPTER V. 
VACCINIA. 

Vaccinia is a mild eruptive disease which occasionally occurs among 
cattle and has been propagated from them to man. It is characterized by 
the appearance upon the surface of one or more papules, which soon become 
vesicular and then pustular. It is communicable by contact, but, unlike the 
other eruptive fevers, it is not contagious through the air. It is inoculable, 
both by the liquid contained in the vesicle, which is designated vaccine lymph, 
and by the scab wliich results from the desiccation of the pustule. 

To Grloucestershire, England, the honor belongs of discovering and utiliz- 
ing the fact that vaccinia, a mild and comparatively harmless disease, is trans- 
missible from the cow to man, and that it affords protection from smallpox. 
It appears that a vague opinion prevailed among the farmers of this dairying 
section that a disease which has since been designated vaccinia was occasion- 
ally received from the cow in milking, the virus passing from a pustule on 
the teat to a sore or chap on the hand of the milker, and that those who thus 
contracted the disease received immunity from smallpox. As usually happens 
with important discoveries, so slow of apprehension is the human intellect, 
these people, to whom Providence had revealed a most important fact, were 



346 VACCINIA. 

blind to its real value. Finally, in tlie year 1724, Benjamin Jesty, whom the 
world has not sufficiently honored, '-an honest and upright man," according 
to his epitaph, a farmer of Gloucestershire, had the courage to vaccinate his 
wife and two children. His excellent moral character did not shield him. 
He was regarded by his neighbors as an inhuman brute, who had performed 
an experiment on his own family the tendency of which might be to trans- 
form them into beasts with horns. 

This first essay in vaccination appears to have been entirely successful, but 
the prejudice against the operation continued. A fifth of a century passed, 
during which there was no extension of the benefits of this great discovery. 
At last, toward the close of the last century, Dr. Edward Jenner, a physician 
of Gloucestershire, an inoculator of his district, began to investigate this dis- 
ease of the cow, about which little was known, and the grounds for the belief 
that it afforded protection from smallpox. Fortunately for the world, Jenner 
had been educated under John Hunter, and had learned from his great mas- 
ter to study nature rather than books — to be guided by experience and obser- 
vation rather than by the dogmas of his predecessors or of the schools. 

Jenner performed his first vaccination on the 14th of May, 1796, twenty- 
two years after Benjamin Jesty had lost his good name among his neighbors 
by vaccinating his own family. The popularizing of vaccination, mainly 
through Jenner's perseverance, affords one of the most interesting and in- 
structive chapters in the history of medical science — how he went to London 
full of the importance of the discovery, and was there advised by his medical 
friends to desist from his wild schemes, lest he should injure the reputation 
which he had gained from a creditable paper on the habits of the cuckoo ; 
how he was finally allowed to vaccinate in hospital wards, and gained some 
adherents to the new faith among the leading physicians of the metropolis ; 
and, finally, how, as the claims of vaccination began to be recognized at the 
close of the last century and commencement of the present, a most acrimo- 
nious discussion arose which filled all the medical journals of that period. 
The opponents of vaccination resorted to every device to prevent the accept- 
ance of Jenner's views. They attempted to prejudice the people against 
them by specious arguments, by ridicule, and even by caricatures. One of 
the leading journals contained the picture of a cow covered with sores and 
devouring children, and it was urged that vaccination was a bestial operation, 
degrading man to the level of the brute. But the truth had gained a firm 
hold and the practice of vaccination extended. 

The discovery of vaccinia and of its protective power cannot be too 
highly appreciated. It has probably done more to relieve human suffering 
than any other discovery of the last one hundred years, unless we except 
that of anaesthetics, and more to save human life than any other instrument- 
ality of a purely physical kind. 

The fact was established in the time of Jenner that the virus of small- 
pox inoculated in the cow produces vaccinia, which in its propagation back 
to man never returns to its original form, but always remained vaccinia. 
Moreover, Jenner believed that the disease known in the horse as the grease 
was identical in nature with vaccinia in the cow. He failed, however, in his 
experiment to communicate vaccinia from the horse, but other experiments 
have been more successful. In 1801 a Dr. Loy of the county of York, Eng- 
land, met two cases of vaccinia in persons who had taken care of a horse 
affected with the grease, and from the lymph which he obtained was able to 
produce vaccinia in the cow. In 1805, Viborg. a Danish veterinary surgeon, 
after many failures, succeeded also in communicating vaccinia to the cow by 
means of the virus taken from a horse. 

From this time little light was thrown on this subject till within the last 



VACCiyiA. 347 

twenty years. Although Loy and Viborg, and perhaps a few others, had 
recorded their success, other experimenters had failed to communicate vac- 
cinia from the horse. In the absence of additional cases the profession began 
to question whether there might not have been some error in the observations 
of the gentlemen whose names I have mentioned, and whether a disease iden- 
tical with vaccinia, or a disease which may communicate vaccinia to the cow 
or to man, occurs in the horse. 

Observations confirmatory of those of Loy and Viborg were at length, 
however, made, which must be regarded as conclusive. In 1856, in the 
department of L'Eure-et-Loir, France, 31. Pichot was consulted by a boy 
who had on the back of his hands vaccine pustules which had apparently 
reached the eighth or ninth day. He had not taken care of nor been in con- 
tact with a cow, but had a few days before taken care of a horse affected with 
the grease. Vaccination was performed by means of the lymph taken from 
the pustules, and genuine vaccinia was produced. 

Again, in 1860 an epidemic prevailed among the horses in Riemes and 
Toulouse, France. A mare sickened with the disease, and there was swell- 
ing of the hough, with discharge of sanious matter. M. Delafosse vacci- 
nated two cows with this matter and communicated genuine vaccinia. This 
epidemic was believed by the veterinary surgeons to be an eruptive fever, 
difi'ering in its nature somewhat from the disease or diseases which have ordi- 
narily been designated the grease. It has been conjectured that two or more 
distinct affections of the horse have the same appellation — one of which, it is 
now admitted, is identical with vaccinia of the cow and may communicate it ; 
and the reason why so many experimenters have failed to vaccinate the cow 
from the horse is that they have used the virus of the wrong disease, or have 
taken virus from horses which had been affected with true disease, but from 
ulcers which had lost their specific character. 

Prior to the time of Jenner variolous inoculation was practised in most 
civilized countries, since variola produced in this way was found to be milder 
than when arising from infection. This practice is now obsolete, forbidden 
in some places by legislative enactments. It is superseded by vaccination. 
Vaccination, or the introduction of vaccine lymph into the system, is quickly 
and conveniently performed by scarifying with a lancet and rubbing into the 
incisions the lymph or a little of the scab pulverized and dissolved in a drop 
of cold water. It may also be performed by scraping off the epidermis with 
the edge of the instrument till the blood begins to ooze : and also, though 
with less certainty of success, by puncturing the skin with the point of the 
lancet or by an instrument called the vaccinator. The scab should never be 
employed when it is possible to obtain pure lymph, since it contains animal 
matter apart from the virus, and may be the medium through which other 
diseases may be communicated. Besides, it is much less active than pure 
lymph. 

If the child have a vascular n^evus, this may be selected as the point of 
vaccination. Unless of large size, it can usually be cured by the inflammation 
which vaccinia produces. Statistics collected by Simon, as well as Marson, 
show that in those who contract varioloid the larger the number of vaccine cic- 
atrices the milder the disease and the less the proportionate number of deaths. 
In Simon's statistics of those who stated that they had been vaccinated, but 
who presented no cicatrix, 21f per cent, died ; of those who had one cicatrix. 
7* per cent, died ; of those who had two. 4^ per cent, died : of those who had 
three. It per cent, died : while of those who had four or more cicatrices, only 
f per cent. died. These statistics would seem to indicate the propriety of 
vaccinating in several places. But, so far as appears, when two or more 
cicatrices were observed the patients may have been vaccinated at different 



348 VA CCINIA. 

times, at intervals of several years ; and if so the inference would not follow 
that more complete protection is produced by vaccinating in several places 
than in one. 31oreover, if vaccination be performed in the usual manner by 
several incisions on the arm, and the virus be fresh and active, usually two 
or more distinct vesicles arise, which unite in their development and probably 
protect the system as much as if they were separated by a wider space. 

Appearances ; Symptoms. — In genuine vaccination no effect is ob- 
served, except the slight inflammation due to the operation, till the close of 
the third day. Then the specific inflammation commences. This is indi- 
cated by a small red point, at first scarcely visible, indurated and slightly 
elevated, as determined by the touch rather than by the eye. This increases, 
and on the fifth day the cuticle over the inflamed part begins to be raised by 
a transparent and thin liquid. The vesicle increases in diameter, and by the 
sixth day presents an umbilicated appearance and is surrounded by a faint 
and narrow red zone. At the close of the eighth day the vesicle is fully 
developed. Its size varies considerably. It is usually from a sixth to a 
third of an inch in diameter, and oval or circular. If the vaccination 
have been performed by incisions, the size of the matured vesicle may 
be considerably larger and its shape irregular, in consequence of the union 
of two or more vesicles. The eruption now presents a whitish or pearl- 
colored appearance, due to the whiteness of the cuticle and the transparence 
of the liquid underneath. If the vaccination be performed by incisions, it 
is not unusual to observe over the centre of the vesicle, and adhering to it, 
a small yellowish scab, which has resulted from the scarification and which 
contains none of the virus. 

The vaccine vesicle, like that of variola, consists of compartments, com- 
monly eight or ten, with complete partitions, so that there is no intercom- 
munication. On the ninth day the inflamed areola becomes more distinct 
and its diameter rapidly increases. Its color is deep red, its temperature is 
considerably elevated, and it is accompanied by more or less induration of 
the subcutaneous tissue, and it is tender to the touch. On the tenth day 
the pock has reached its full development. The areola extends from one to 
two inches away from the vesicle, becoming fainter at its outer circumfer- 
ence and gradually disappearing in the healthy skin. The shape of the 
outer circumference of the areola is irregular, projecting farther at one point 
than another, though its general form is circular. 

On the tenth day, when the inflammation has reached its maximum, the 
heat, itching, and tenderness in and around the pock are such that the child 
is often feverish and restless. Occasionally the glands of the axilla become 
swollen and tender. In other cases, in which there is but a moderate amount 
of inflammation, the constitutional disturbance is slight. 

At the close of the tenth day or on the eleventh the inflammation begins 
to decline ; the areola becomes narrower and then disappears ; the induration 
and tenderness abate ; and with this change the pustule desiccates, its liquid 
is absorbed, and there results a brownish or dark mahogany-colored scab, 
which is detached, ordinarily, between the fourteenth and twenty-first days. 
The cicatrix, at first reddish like all recent cicatrices, gradually becomes paler, 
and remains whiter than the surrounding integument. It presents several 
minute depressions or pits, which indicate the genuineness of the vaccination. 

The theory that smallpox becomes vaccinia by passing through the heifer, 
as we have given it above, has for many years been undisputed. But recent- 
ly the theory has been promulgated that vaccinia and variola, instead of 
being forms of the same disease, are essentially distinct — that when the heif- 
er is inoculated with the virus of smallpox, the disease which is produced is 
a modified smallpox, but not vaccinia, which occurs as a spontaneous disease 



ANOMALIES, COMPLICATIONS] AND SEQUELS. 349 

among cattle. It may be that the old theory, which no one doubted until 
recently, is wrong, but that vaccination prevents smallpox just as a mild 
attack of scarlet fever prevents a severe attack of the same disease, shows, 
in my opinion, a close relationship between vaccinia and the severe malady 
which it prevents. We wait for more conclusive facts m support of the 
new theory before accepting it. 

Anomalies, Complications, and Sequels. — The vesicle is often 
broken accidentally or by the nails of the child. If the top of the vesicle 
be destroyed or most of the compartments be opened, the inflammation is 
commonly increased, considerable suppuration occurs, and there results a 
large, irregular, yellowish scab consisting of the virus mixed with desiccated 
pus. The scab is entirely unreliable and unfit for the purpose of vaccina- 
tion, though the protective power of the disease is not diminished by injury 
of the vesicle even if it be totally destroyed. The cicatrix which results 
from extensive injury to the vesicle is usually large and without the indented 
points which characterize the normal cicatrix. 

In rare cases, when the inflammation which surrounds the vesicle is 
intense and deep seated, suppuration occurs in the subjacent connective 
tissue, giving rise to an abscess. This abscess is commonly of small size, 
but it increases the fretfulness and constitutional disturbance which attend 
vaccinia. This subcutaneous suppuration occurs most frequently in those 
who have a scrofulous or vitiated state of system. Inflammation of the 
lymphatic glands of the axilla I have spoken of as not infrequent in vaccinia. 
This sometimes proceeds to suppuration, producing an unpleasant though not 
serious complication. 

It sometimes happens that vesicles appear in other parts besides the 
points where the virus was inserted. These supernumerary vesicles com- 
monly occur where the cuticle has been removed by scalds or injuries. 

Trousseau relates the case of an infant whom he had vaccinated. On the 
eleventh day he was astonished to find twelity-seven vaccine pustules on the 
face, trunk, and limbs. This infant had, however, before the vaccination a 
simple non-specific eruption over the whole body, and it was believed that it 
had produced these vaccinations by transferring the lymph with its nails to 
the various parts where the cuticle was denuded. 

It is not unusual, also, to observe minute papules appearing on parts of 
the surface simultaneously with or soon after the vesicle, and in a few days 
declining. These seem to be abortive vaccine eruptions. 

One of the most serious complications is erysipelas. This may occur 
directly from the operation or from the inflammation caused by the vesicle 
when the virus possesses no deleterious property ; and, again, it may result 
from some unknown element in the virus. It may occur immediately after 
the operation, when it commonly prevents the working of the virus, or during 
the vesicular or pustular stage, or, again, after desiccation and separation of 
the scab. I have observed it at all these periods. 

Erysipelas, occurring as a complication of vaccinia, is invariably referred 
by the friends to the virus employed, and the physician who has had the mis- 
fortune to vaccinate is often unjustly blamed. In many of these cases there 
is a strong predisposition to erysipelas at the time of the vaccination, and 
the operation or the inflammation which accompanies the normal develop- 
ment of the vesicle serves simply as an exciting cause. Erysipelas would 
occur as soon from a non-specific sore ; indeed, we not infrequently are called 
to cases of this disease in young children which commence from non-specific 
sores upon the genitals or on one of the limbs. That the fault is not in the 
virus employed is evident from the fact that other children, vaccinated with 
the same, have simple uncomplicated vaccinia. 



350 VACCINIA. 

Sometimes, on the other hand, the cause of erysipelas, whatever it may be, 
exists in the virus. (For further facts in reference to this subject the reader 
is referred to our remarks on erysipelas.) 

The fact is established by many observations that syphilis is communi- 
cable by vaccination. The symptoms of it may not appear till vaccinia has 
terminated or for a little time subsequently, but it then constitutes a very 
serious sequel. A physician of this city, well known in this community as 
skilful in the diagnosis and treatment of skin diseases, and therefore not 
likely to be mistaken as regards the nature of the diseases, states that he 
communicated syphilis to two infants by vaccinating with the same scab. 
Both had the characteristic syphilitic eruption. In January, 1868, an infant 
was brought to Prof. Alonzo Clark's clinique in this city having syphilitic 
rupia, which in the opinion of the physicians present was undoubtedly the 
result of vaccination. 

Trousseau relates the case of a young woman eighteen years old who was 
vaccinated with virus taken from an infant apparently in perfect health. The 
vaccination was unsuccessful, but twenty-three days subsequently his atten- 
tion was called to an eruption which had appeared in two places on the woman's 
arm corresponding with the points where the virus had been inserted. The 
eruption was that of ecthyma, which by the next examination, which was 
five days subsequently, had been transformed into rupia. The axillary lym- 
phatic glands were tumefied and indolent ; finally roseola appeared, which 
removed all doubts as to the syphilitic character of the disease. There was 
syphilitic infection, which first manifested itself in the points where vaccina- 
tion had been performed (Article de la Vaccine). It is not ascertained in 
Professor Clark's case, nor is it stated in Trousseau's, whether the lymph or 
scab was employed for vaccination. There can be little doubt that the pure 
lymph never communicates anything but vaccinia, and if by vaccination any 
other disease be imparted, a little blood has mingled with the lymph or the 
scab has been employed. 

The vesicle in genuine vaccinia is sometimes very small, not having a 
diameter of more than two lines. Occasionally the development of the 
vesicle is retarded. It does not appear till two or three days later than 
the usual time, or even a longer period. 

Vaccinia is modified by certain diseases. It is arrested by measles and 
scarlet fever, pursuing its course after the subsidence of the exanthem. On 
the other hand, it sometimes modifies the paroxysmal cough of pertussis, but 
only during the time when the pock is maturing. Eczematous eruptions 
occasionally occur after vaccinia, as they often do after the other eruptive 
fevers, or if already present they may be aggravated. 

Subsequent Vaccinations. 

A second vaccination, performed prior to the ninth day after the first vac- 
cination, is successful. A genuine vaccine eruption results, which is smaller 
the more advanced the primary disease. This second eruption overtakes the 
first. On the ninth day the susceptibility to vaccinia is, in most cases, lost, 
so that vaccination performed on the tenth or subsequent days is unsuc- 
cessful. 

As a rule, an acute contagious disease occurs only once in the same 
individual. Vaccinia is an exception. In most people, after a few years it 
can be produced a second time, and cases of a third or fourth successful vac- 
cination at intervals of a few years are not uncommon. Now, subsequent 
cases of vaccinia difi"er from the first, which has been described above. The 
period of incubation is shorter, and the vesicular, pustular, and desiccative 



PROTECTION FROM VACCINATION— RE VACCINATION. 351 

stages succeed each other more rapidly, so that the whole period of the dis- 
ease is less. The variation from the appearance and course of the first ves- 
icle is proportionate to the degree of protection which the first vaccination 
still affords both as regards smallpox and vaccinia. If several years have 
elapsed since the first vaccination, and the protective power which it affords 
is nearly lost, the second vaccinia differs but little from the first. If, on the 
other hand, the first vaccination still affords nearly complete protection, the 
result of the second is slight ; the eruption is insignificant, lacking the cha- 
racteristic appearance of the vaccine vesicle, resembling a common sore, and 
disappearing within a week. It is not accompanied by the inflamed areola or 
any appreciable constitutional disturbance. 

Vaccination often produces no result. This is sometimes due to the fact 
that the lymph or scab employed is useless. It has spoiled by keeping or 
never has been good. In other cases it is due to a lack of susceptibility in the 
person. Some take vaccinia with difiiculty and only after several vaccinations ; 
just as children, though fully exposed, often fail to take measles or scarlet 
fever, on account of a condition of the system which prevents the reception 
of the virus or antagonizes and controls its action. In some instances after 
vaccination an eruption is produced which may or may not be genuine, but it 
immediately becomes purulent and is soon broken. A large yellow, uneven 
scab results, having none of the appearance and containing little or none of 
the vaccine virus. This scab, as well as the liquid matter which preceded the 
formation of the scab, is utterly useless for the purpose of vaccination, and 
if so employed will probably cause a sore from its irritating effect, but not of 
a specific character. If, in place of the true vaccine vesicle, the eruption 
presents the appearance which I have described — namely, that of a pustule, 
soon breaking and forming a large irregular, yellowish scab — the vaccinia (if 
it be correct so to designate it) must be considered spurious. A sore has 
been produced by the animal matter which was employed in the vaccination 
along with the virus, which has modified the action of the virus, and prob- 
ably has rendered it useless as a means of protection ; or there may have 
been no virus inserted with this animal matter. The physician should in 
such cases insist on a second vaccination. 

Cases like the above are of frequent occurrence, and the parents of the 
child are often satisfied with the result. They see an eruption following 
vaccination, accompanied by considerable inflammation and leaving a cicatrix. 
Unless undeceived by the physician, they probably remain in the belief of 
the child's security until, perhaps, it takes smallpox. Such cases obviously 
tend to diminish the confidence which the public should have in vaccination 
as a means of protection from smallpox, and on account of their frequent 
occurrence it is important in every case that the physician should see the 
result of his vaccination. It has been proposed, as a means of determining 
the genuineness of vaccinia, to revaccinate when the eruption begins, and if 
the first be genuine the second will overtake it. This is called Brice's test, 
but it is not necessary, since the physician, familiar with the appearance of 
the true vesicle, can determine at once its genuineness by the sight. 

Protection from Vaccination — Revaccination. 

It was believed by the early advocates of vaccination that the general 
performance of this operation would soon eradicate smallpox from the com- 
munity, so that it would be interesting only to the medical historian as a 
scourge of past ages. This result, however, is only partially achieved. As a 
rule, the greater the benefit of any measure designed to ameliorate the condition 
of mankind, the greater and more numerous are the obstacles which diminish 



352 VACCINIA. 

its effectiveness. Science is full of examples of this. Fortunately, these 
obstacles as regards vaccination are not such as to impair the confidence of 
physicians in its protective power, and it is not too much to expect that this 
simple operation will yet be the means of rendering smallpox a disease almost 
unknown, unless in its modified form. 

Vaccination should be performed in the first year of life. In rural dis- 
tricts, where there is little danger of exposure to smallpox, it may deferred 
till the age of ten or twelve months. In the city, on the other hand, where 
there is constant intercourse of people and where contagious diseases are 
often contracted in ignorance of the time and place of exposure, an earlier 
vaccination is advisable. Some physicians recommend performance of the 
operation as early as the age of four or six weeks. The objection to this is 
that if erysipelas occur so young an infant is likely to perish from it, whereas 
an infant three or four months old ordinarily recovers. For this reason I 
believe that the most suitable age is about four months for the city infant in 
ordinary times ; but if smallpox be epidemic, vaccination should be performed 
at an earlier age. I have vaccinated even the new-born infant when smallpox 
had broken out in adjoining apartments. 

Vaccinia usually extinguishes, for a time, the susceptibility to smallpox. 
According to Mr. Gintrac, varioloid does not occur within two years in those 
who have been vaccinated. It may, however, in exceptional instances, occur 
in a mild form within a few months after vaccination. The protection afforded 
by vaccination gradually diminishes by time, but it does not probably, as a 
rule, entirely cease. Varioloid, however, occurring thirty or forty years 
after a successful vaccination is likely to be severe, and it may even be fatal, 
showing that it has been but slightly modified. In other cases, even after so 
long an interval, the symptoms present a degree of mildness which indicates 
that the protective power of the vaccination is not entirely lost. 

If a second vaccination be practised soon after the scab from the first 
vaccination has fallen, it will usually produce no result, but in other cases it 
gives rise to a little redness, swelling, and induration, which show that vaccinia 
has been reproduced, though in a very mild and insignificant form. It is 
probable that in these cases varioloid might also occur by exposure, though 
with a mildness corresponding with that of the vaccinia. The longer the 
period after the first vaccination, the greater the number of those in whom a 
second vaccination is effective, and, as has already been stated, the greater 
also the liability to the variolous disease until the system is protected by a 
second vaccination. A second vaccination should be performed about the 
sixth or eighth year, and a third between the fifteenth and twentieth years. 
If smallpox be epidemic, it is proper to vaccinate all who have not been 
vaccinated within three or four years. 

Selection op Virus. 

The lymph is preferable to the scab for vaccination, provided that it can 
be obtained fresh. The scab is more easily preserved, and therefore, if the 
lymph and the scab be old, the latter is to be preferred. The lymph should 
be taken on the fifth day if the vesicle be sufficiently developed. It may also 
be taken on the sixth, seventh, or even eighth day, provided that the areola 
has not formed. The lymph of the fifth day acts with greater energy, 
though that of the sixth or seventh day is not- much inferior. Lymph 
obtained after the formation of the areola is less efficient, though it may 
communicate the genuine disease. 

There is no mode of vaccination so reliable as the use of lymph taken 
directly from the arm and immediately inserted — the arm-to-arm vaccination. 



VARICELLA. 353 

Lymph can be preserved for a few days on a flattened surface of whalebone 
or the segment of a quill, and if employed within a week it will usually com- 
municate vaccinia. Lymph may be preserved a longer period between two 
surfaces of glass, but the best way of preserving it is in capillary glass tubes. 
The end of the tube is placed within the vesicle, and the lymph ascends by 
capillary attraction. When a sufficient quantity is received, the ends are 
sealed by holding them for a moment in a flame. Care is requisite in doing 
this so as not to heat the lymph, as it is spoiled by a temperature much above 
that of the body. When the lymph is used, the ends of the tube are broken, 
and by blowing gently through it a sufficient quantity is received on the point 
of a lancet. 

If the scab be genuine, it presents a dark-brown or mahogany color, and 
has a circular, oval, or at least a rounded form ; it is firm or compact, and has 
a lustre. Soft, yellowish, and irregular scabs are not genuine, and those of a 
dull appearance or without lustre have usually spoiled in the keeping. The 
scab is best preserved in soft beeswax, which excludes the air, and it should 
be kept in a cool place. It is the belief of many that the vaccine virus grad- 
ually becomes weaker by passing successively through the human system 
(Condie, American Journal of the Medical Sciences^ April, 1865), and that 
therefore diiferent specimens of virus work with different energy according 
to the degree of removal from the cow. To what extent this view is correct 
is not fully ascertained, but certainly if the virus employed continue to pro- 
duce a small vesicle attended only by a little inflammation, there is reason to 
believe that the protection which it imparts is less than that from virus which 
works with greater energy, and it should be exchanged for such. In New 
York we are able to obtain at any time lymph directly from the heifer. It 
has never passed through human blood, for the original lymph came from 
cattle in one of the provinces of France, where vaccinia was prevailing epi- 
demically. The popular objection to vaccination is obviated by the use of 
this lymph, but it works with great energy,- producing a large pock and a 
sore which is often a month in healing. I have found it very reliable, and 
prefer to use it in ordinary cases. 



CHAPTER YI. 

VAEICELLA. 

Varicella, chickenpox, or swinepox is the shortest and mildest of the 
eruptive fevers. It is highly contagious, so that few children escape who are 
exposed to it. Its period of incubation is from fifteen to seventeen days. 
Hutchinson (^Brit. Med. Jour.^ 1881) and Le Gendre (^V Concours Med.., 1887) 
state that varicella is inoculable, but some years ago inoculations which I 
performed with the lymph of the varicellar vesicle were without result. 
It attacks the same individual but once, and it occurs as an epidemic. It 
has been thought by some to prevail most immediately before, during, or 
after epidemics of smallpox, and it has been conjectured that it is a modified 
form of variola, and hence its name, which signifies little variola. This idea 
is, however, entertained by few, and it is opposed by the following facts : Vari- 
cella may occur after variola or variola after varicella without any modifica- 
tion, and the two diseases are very dissimilar as regards gravity of symptoms 
and duration. The variolous disease, whether smallpox or varioloid, often 

23 



354 VARICELLA. 

occurs in the adult; varicella, on the other hand, is a disease of infancy and 
childhood. I have seen one adult case, which I recall to mind, and Professor 
Flint states that he has also observed it, but its occurrence at this period of 
life is rare. Senator relates a case that occurred at the age of eleven days. 
In 584 cases observed by Baader'the ages were as follows: 

Cases. • Age. 

382 1-5 years. 

191 6-10' " 

7 11-15 " 

2 16-20 " 

2 21-40 " 

Moreover, varicella and variola have been known to occur simultaneously in 
the same individual. Such a case was reported by M. Delpech in a memoir 
published in 1845. 

Symptoms. — Varicella usually commences with such symptoms as usher 
in ordinary mild febrile attacks — namely, headache, languor, chilliness, and 
sometimes aching in the back and limbs. Fever supervenes, which is usually 
moderate, the pulse rising perhaps to 100 or 112, and the thermometer show- 
ing an increase of temperature^ but less than occurs in the other eruptive 
fevers.' These symptoms which precede the eruption are sometimes absent 
or are so mild as to escape notice. The fever usually ceases on the second 
day, but it may return on the following night. The appetite is rarely lost, 
and most children continue more or less at their amusements. 

When the above symptoms have continued about twenty-four hours the 
eruption appears first over the trunk, and soon afterward over the face and 
limbs. It consists of minute disseminated papules which become vesicular 
in the course of a few hours. The occurrence of the vesicular stage is nearly 
simultaneous on all parts of the surface, and commonly fresh vesicles appear 
during the first three or four days. The vesicles lack the hard, indurated 
base of the variolous eruption, though they are sometimes surrounded by a 
faint zone of redness. They differ also from the variolous eruption in the 
absence of umbilication and in irregularity of shape. Some are small and 
acuminate, some hemispherical and of medium size, and others oval or elon- 
gated and of large size. The inflammation is quite superficial, not involving 
the subcutaneous tissue and scarcely affecting the deepest layer of the skin. 

The vesicles vary in size from the diameter of half a line to that of even 
three lines. They occasionally give rise to slight itching. On the second 
day of the eruption or third day of the disease they are still fully developed, 
their liquid contents being nearly transparent. At the close of this day the 
liquid begins to be somewhat cloudy and its absorption commences. On the 
fourth day of the disease desiccation progresses rapidly, and by the fifth the 
liquid has for the most part disappeared, and a scab results, small, thin, and 
of a yellowish-brown color. The scabs are soon detached, the redness which 
indicated their seat disappears, the epiderm which had been raised and 
removed by the eruption is reproduced in its normal state, and in a few days 
all evidence of varicella is effaced. A cicatrix occasionally results, but it is 
due not to the simple varicellar eruption, but to a sore produced from the 
eruption by the scratching of the child. 

The number of vesicles varies considerably in different cases. They are 
never, so far as I have observed, confluent ; but they are sometimes so abun- 
dant in young children that if the disease were variola it would be called 
severe discrete. They occur also on the buccal and faucial surfaces, where 
they soon break, forming small ulcers. The duration of the disease from 
the first symptoms until the disappearance of the crusts is eight or ten days. 



COMPLICA TIONS—TREA TMENT. 355 

Mr. J. Hutchinson of London has described a rare form of varicella in 
which the eruption becomes gangrenous. It occurs most frequently in feeble, 
ill-conditioned children, but sometimes in those who are well nourished. Only 
a portion of the vesicles become gangrenous. Where the gangrene occurs a 
deep and unhealthy ulcer forms underneath the scab, which does not heal or 
heals slowly. This rare form of varicella is very fatal, death sometimes 
occurring from pyaemia and secondary abscesses. Crocker states (^London 
Lancet^ May 30, 1885) that the gangrene sometimes occurs upon a part of 
the surface which is not the seat of the eruption. 

Complications ; Sequels. — Complicating maladies which sometimes 
supervene in varicella do not, for the most part, occur in consequence of 
this disease, but are independent of it. Erysipelas has in rare instances 
supervened on the varicellar eruption, but its occurrence is attributable to 
the ordinary causes of this disease, rather than to varicella. .Various seque- 
lae of varicella have been mentioned by writers, among which we may 
mention aneemia, pemphigus, urticaria, bronchitis or bronchi-pneumonia 
(Meigs and Pepper), ulcers leading to glandular enlargements and tuber- 
culosis, and nephritis (Henoch, Janssen, Oppenheim). 

Diagnosis. — Obviously, the only diseases with which varicella is liable 
to be confounded are such as present vesicles at some stage of their course. 
From the local vesicular eruptions this disease is diagnosticated by the fact that 
the vesicles appear on all parts of the surface. It is sometimes mistaken for 
variola or varioloid, or vice versa. — a mistake very damaging to the reputation 
of the physician. The points of differential diagnosis are the symptoms of 
invasion — severe and lasting three or four days in the one, mild and continu- 
ing onl}^ one day in the other ; an eruption passing slowly through its stages 
from the papular to the pustular, umbilicated, with circular, raised and 
inflamed base, appearing first on the face and neck, and not till a day later 
on the legs, in the one disease; while in the other the evolution, shape, and 
course of the eruption, as described above, are materially different. By 
proper attention to these distinctive features it is rarely difficult to diagnosti- 
cate varicella. 

Prognosis. — In ordinary uncomplicated varicella this is always good. 
Gangrenous varicella, which is very rarely seen in America, may be fatal, 
and complications may render a case grave. 

Treatment. — On account of the general mildness of varicella, prophy- 
lactic measures, as isolation of the patient, are seldom enforced in America, 
and the disease, when not com.plicated or gangrenous, requires little treat- 
ment ; but the patient should be quiet and indoor during its continuance. 
Large vesicles upon the face should be punctured early and irritation by 
rubbing should be avoided. Complications and gangrenous varicella require 
appropriate treatment, especially supporting remedies. Anaemia or gland- 
ular swellings remaining after varicella require tonics, especially cod-liver oil 
and syrup of the iodide of iron. 



356 DIPHTHERIA. 



CHAPTEK yil. 

DIPHTHERIA. 

Diphtheria is one of the most dreaded, one of the most fatal, and 
unfortunately one of the most common, maladies of childhood. It is believed 
to be produced by a micro-organism. It is characterized by the occurrence 
of a grayish-white pellicle upon the mucous surface or the skin deprived of 
its protecting epithelium. The specific principle is ordinarily received by the 
inspiration of infected air, but it is sometimes received by direct contact of 
infected matter with one of the surfaces not lying in the respiratory tract. 

Diphtheria is a disease of antiquity. M. Sanne mentions the following 
names by which it has been known in different countries and at different 
periods : ulcus Syriacum, ulcus ^gyptiacum, garrotillo, morbus suffocans, 
affectus strangulatorius, pestilentis gutturis affectio, pedancho maligna, angina 
maligna, anginosa passio, mal de gorge gangreneux, ulcere gangreneux, 
angina polyposa, angine maligna, croup, diphtheritis, diphtheria. These terms, 
expressing the prominent characteristics of diphtheria, render it probable that 
this was the disease alluded to. 

It is impossible to state or form a probable conjecture in regard to the 
time when diphtheria originated, but its origin probably antedated the Chris- 
tian era. According to Aurelianus, Asclepiades, who lived one hundred 
years before Christ, scarified the tonsils and performed laryngotomy for the 
relief of respiration, and it is supposed that he treated cases of membranous 
croup, and probably diphtheria. Aretaeus, a Greek physician of Cappadocia 
at the commencement of the Christian era, gives in writings still extant a 
clear and accurate description of mild and severe diphtheria. After describ- 
ing what he designates ulcers upon the tonsils, " covered with a white, livid, 
or black concrete product," he adds : " If the malady invades the chest by 
the trachea, it causes suffocation on the same day. Children up to the age 
of puberty are most exposed to this disease." He gives also a graphic and 
truthful description of the suffering of the child when the disease extends to 
the larynx, and croup results. Galen, in the second century, apparently 
alludes to diphtheria when he describes a fatal disease prevalent in his time 
in which fragments of " membranous tunic " are expelled. He states that he 
is able to determine by the manner in which the fragments are expelled, by 
coughing or spitting (hawking), whether they are detached from the larynx 
or the pharynx. Coelius Aurelianus, a Latin physician who is supposed by 
some to have lived in the second century, and by others as late as the fifth 
century, describes a grave angina in which the symptoms which sometimes 
arisp correspond with those in diphtheritic croup and diphtheritic paralysis as. 
observed at the present time. In the fifth century Aetius of Amida described 
a disease accompanied by " crusty and pestilential ulcers," sometimes having 
a whitish and in other instances an ashy or rusty color, and not preceded by 
a discharge. Aetius alludes to the hoarseness which he says sometimes super- 
venes and is a source of danger up to tfie seventh day. 

From the close of the fifth century until the sixteenth the record of 
diphtheria is broken. It is probable that during the long period embraced 
in the Dark Ages every decade witnessed epidemics of this fatal disease, 
but if they were observed and recorded the re-cords were lost, the literature 



DIPHTHERIA. 357 

of diphtheria sharing the fate of general literature during this time of intel- 
lectual darkness. 

In the sixteenth century epidemics of diphtheria occurred in various 
parts of Europe, and clear and unmistakable descriptions of them have been 
preserved. From the sixteenth century until the present time diphtheria has 
continued to be one of the most frequent and fatal of the epidemic diseases 
upon the European continent, and it is apparently permanently established in 
its great cities. 

It is a remarkable fact that those pestilential diseases which desolate 
families and communities in modern times originated in the Eastern hemi- 
sphere, chiefly in Asia or Africa, and extended to the Western nations through 
commerce or navigation. The aborigines of America had in their primitive 
state no ailments, so far as we can ascertain, except such as occurred from 
vicissitudes of temperature or were incident to age and their wild and exposed 
nomadic life. Pernicious to them was the discovery of America by Europeans 
for various reasons, but especially because it led to the introduction of the 
contagious and pestilential maladies. The cruel and rapacious gold-hunters 
under Cortez introduced smallpox into Mexico, and for ages afterward 
throughout Central America heaps of skeletons of those who perished of 
this disease were found in shaded and out-of-the-way localities where they 
had been taken by their friends. Adventurers from the Old World intro- 
duced the eruptive fevers and the loathsome contagious diseases of vice and 
immorality into the islands and upon the continent of North America. The 
medicine-men of the Indians had by their incantations gained great repute in 
the management of the diseases with which they were familiar in their wild 
life in the forests, but they were unable to cope with the new diseases which 
the vessels of the foreigner had brought to this Western World. 

Of all the diseases which America has received from Europe, the one 
most dreaded, because of its highly contagious character, the great mortality 
which attends it, and the extreme suffering which certain forms of it produce, 
is diphtheria. It is to be, from appearance, above all other maladies the 
scourge of America in the future. It is probable that the first cases of 
diphtheria in America occurred in or near Boston. Josselyn made two voy- 
ages to New England in 1638 and 1663, remaining eight years in this country 
after his second arrival. He states that the Europeans residing in New 
England are greatly afflicted by a disease " which hath proved mortal to some 
in a very short time, quinsies and impostumations of the almonds, with great 
distempers of colds." ^ At Roxbury, Massachusetts, in 1659, three children 
in a family were attacked by the " malady of bladders in the windpipe," all 
dying within two weeks.^ 

At the close of the seventeenth century and in the first half of the 
eighteenth century epidemics of diphtheria occurred in various parts of New 
England. At Kingston, New Hampshire, in March, 1735, a child died of 
three days' sickness of a throat affection. A week subsequently three chil- 
dren in another family, four miles distant from the first case, also died of a 
three days' sickness. The malady continued to spread and the first forty 
cases all perished. They died of a disease located in the throat, neck, and 
air-passages, attended in many of them by swelling of the cheek or neck. 
The disease from Kingston spread to other townships, but in its subsequent 
course it was milder than at first. We recognize in this nameless disease the 
characteristics of diphtheria. 

In August, 1735, in Boston, a child had a disease of the fauces attended 
by white spots. In the following month several similar cases occurred in 
different parts of Boston. In October of the same year a young man lately 
^ Wm. Veazie, Boston, 1865. 2 Historical Researches of Dr. Elsworth Eliot. 



358 DIPHTHERIA. 

arrived from Exeter, New Hampshire, where a brother had died of this new 
disease, himself sickened with it in a more severe form than had yet occurred 
in Boston. Diphtheria, thus established in Boston, was epidemic during the 
following winter and spring months. At the height of the epidemic, in the 
second week of March, 1736, the burials increased from an average of ten to 
twenty-four through the prevalence and severity of the new disease. Two 
years later (1738), a monograph appeared from the pen of I. Dickinson, A. M., 
Boston, bearing the title, " Observations on that Terrible Disease vulgarly 
called the Throat Distemper, with Advices as to the Method of Cure, in a 
letter to a friend." The writer of this epistle, though a clergyman, appears 
to have been a close observer. He probably, as was not unusual at that 
period, practised both as physician and clergyman. Dickinson's graphic 
description shows that the disease in his day presented the same character- 
istics as at present. 

Diphtheria, thus established in Eastern New England, spread westward 
through the intercourse of the inhabitants, reaching New York in about two 
years. Dr. Cadwallader Golden, writing in 1753, had already carefully 
observed diphtheria. He remarks : " When the disease first appeared it was 
treated in the usual way for a common angina, and no plague was more 
destructive The orifices made by the lancet in bleeding and the adja- 
cent parts were apt to become diseased ; so likewise the places where blisters 
were applied." He recognized the fact, now well known, that in exceptional 
cases the throat remains unaffected, while the diphtheritic inflammation and 
exudate appear upon other surfaces : " A girl about ten years of age, while the 
throat distemper was prevailing, had sores on her private parts, like those on 
the tonsils of others, but no symptom of the disorder appeared in her throat." 
Dr. Jacob Ogden, writing from Jamaica, Long Island, in 1769. and again in 
1774,^ described diphtheria as it occurred in his practice and in the adjacent 
townships. He recommended the use of senega and calomel. But the 
American physician of this period whose writings contributed most to a 
correct understanding of diphtheria was Samuel Bard of New York (1771). 
He possessed a mind admirably qualified for scientific investigations, and 
especially for study of an obscure disease, basing his opinions upon accurate 
clinical examinations. A recent appreciative reviewer. Dr. John C. Peters, 
says : " Bard's article is among the calmest, wisest, and most accurate that 
has ever been written on diphtheria, both before and since his time." He 
recognized the fact that the various forms of diphtheritic inflammation were 
identical in nature, and, however differing in appearances, had the same 
underlying cause. 

In the first half of the present century diphtheria was regarded as a very 
important disease in Europe, and was made the subject of investigation by 
the most renowned clinical teachers, among whom we may mention Jurine 
(1807), Bretonneau (1821), Bourgeoise (1823), Gendron (1825), Billard 
(1826), Deslandes (1827). Blanquin (1828), Broussais (1829), Trousseau 
(1830), Cheyne (1833), Fricout and Burley (1836), Boudet (1842), Guersant 
and Blache (1844), Moland (1845), Damot (1846), and Heine (1849). During 
this half century, ending with 1850, which witnessed such an augmentation 
of the literature of diphtheria in Europe, this disease attracted but little 
attention in America. It appears to have been much less prevalent on this 
continent than in the Old World. It may have occurred in small epidemics 
in various localities from the time of Dr. Bard until 1850, but they attracted 
so little notice from American physicians that no monograph or communica- 
tion to medical journals relating to diphtheria, which was worthy of preserva- 
tion, appeared during this long period. 

^ See Medical Report, vol. v., 1802. 



DIPHTHERIA, 



359 



Since 1850 epidemics of diplitlieria have occurred in numerous localities 
in North America, not only in the cities with their sewers and crowded 
tenement-houses rendering the air impure, but also in the sparsely-settled 
and mountainous sections, where no impurities in the air exist. But diph- 
theria is most prevalent and fatal in the cities. During the last quarter 
century it has become established in most of the larger cities in the Northern 
and AVestern States from the Atlantic to the Pacific coast, along the line of 
commerce and travel. The permanent establishment of diphtheria in the 
centres of trade and travel, and the fact that many have this subtle malady 
in so mild a form that they are not aware of it, and mingle with others in 
places of resort, inevitably tend to disseminate the disease throughout the 
country. Hence in rural localities intervening between the cities outbreaks 
of diphtheria of unknown origin are common in at least all the eastern, 
northern, central, and western portions of the United States and in Canada. 
Consequently, in the last two decades in America diphtheria has been the 
subject of discussion at numerous meetings of medical societies, many cases 
of interest have been reported, and histories of epidemics and statistics of 
treatment have been published in the medical journals. Therefore, the 
American literature on diphtheria is abundant and rapidly accumulating, 
and to the genius and perseverance of an American (O'Dwyer) the world 
is indebted for the means of combating more successfully than in former 
times the most painful, most dreaded, and most fatal form of diphtheritic 
inflammation. 

In Europe diphtheria is established in the centres of medical education, 
as Paris, Berlin, London, and more recently Vienna. It has in these cities, 
and in smaller cities and towns where it has occurred, been the subject of 
much discussion and investigation. In Europe, therefore, as well as in 
America, the literature of diphtheria has been greatly increased during the 
last decade by reports of cases, histories of epidemics, and statistics of treat- 
ment. In six consecutive months in 1888 the deaths from diphtheria in ten 
of the principal cities of Europe were as follows : 



Deaths. Population. 

Paris , . 1047 2,260,945 

London . 852 4,282,921 

Berlin 523 1,414,980 

St. Petersburg .... 341 928,016 

Vienna 251 1,212,232 



Deaths. Population. 

Buda-Pesth 207 442,787 

Copenhagen 210 300,000 

Christiania 196 135,600 

Prague 161 300,828 

Amsterdam 136 390,016^ 



In Madrid, with a population increasing from 136,663 in 1880 to 157,965 
in 1885, the deaths from diphtheria during the six years ending with 1885 
were as follows : 



In 1880 
" 1881 
" 1882 



242 

799 

587 



In 1883 1027 

" 1884 1079 

" 1885 13502 



Among the American physicians who have recently advanced our know- 
ledge of diphtheria are Drs. Curtis and Satterthwaite of New York, in their 
" Keport on the Pathology of Diphtheria," made to the New York Board of 
Health ; Drs. Wood and Formad of Philadelphia, in their " Memoir on the 
Nature of Diphtheria," prepared and published by the National Board of 
Health in 1882 ; and Drs. A. Jacobi and C. E. Bellington in their treatises on 
diphtheria (1880, 1889). In Europe during the same period interesting and 
instructive monographs have been published by Peters, Birch-Hirschfeld, 

1 Bull gen. de Ther., October 30, 1888. 

2 xa Higiene, October, 1888. 



360 DIPHTHERIA. 

Rosenbach, Leyden, Wagner, Fiirbringer, Fisclil, Weigert, Meyer, and 
others. 

Etiology. — During the last twenty years numerous experiments and 
microscopic examinations have been made in order to elucidate the cause 
and nature of diphtheria. Each year of investigation has strengthened 
the belief that the cause is a microbe, but it is still a matter of doubt which 
microbe is the causal agent, or whether there may not be more than one 
species of bacteria which by their action upon and in the tissues produce 
diphtheria. 

Between the years 1868 and 1873 many of the leading pathologists of 
Europe believed that the cause of diphtheria had been discovered — that it 
was the micrococcus or spherical bacterium. During the decade commencing 
with 1868 no subject in pathology attracted so much attention as the relation 
of the micrococcus to diphtheria. Oertel (1868) discovered micrococci in 
the diphtheritic pseudo-membrane and in the blood, lymphatic vessels, and 
kidneys in severe diphtheria, appearing as " point-like, dark-contoured, round 
or oval little bodies isolated, and in zoogloea." In later investigations (1874) 
he found a larger or smaller number of the bacterium termo accompanying 
the micrococcus, and he expresses more firmly the belief that micrococci 
lodging on the mucous surface cause the diphtheritic inflammation. He pro- 
duced croup in rabbits by applying ammonia, and found few or no micrococci 
in the false membrane, and never in the blood or internal organs. He inocu- 
lated the trachea of rabbits, pigeons, and chickens with the diphtheritic 
membrane, and produced local lesions apparently identical with those of 
diphtheria in man, and the blood of the animals subjected to the experiment 
contained micrococci in abundance. Nassilof^ states as the result of his 
observations that fungi, not designating the species, are always present in 
diphtheritic membranes and precede their development, and that they pene- 
trate the tissues by the blood-vessels and lymphatics before any observable 
change occurs in the tissues. Therefore he believes that they cause the 
diphtheritic imflammation. Hueter and Tommasi inserted particles of the 
diphtheritic membrane in the back of the rabbit. Death occurred in forty 
hours. Micrococci were found at the seat of the injury and, before death, in 
the blood of the animal. Similar experiments and observations made by 
other pathologists of renown strengthened the belief that the cause of diph- 
theria had at last been discovered in the micrococcus. Cohn (1872 and 1873) 
classified this organism, which had now assumed great importance, with the 
schizophytes, tribe sphsero-bacteria, and he designated it micrococcus d/ph- 
theriticus. 

On the other hand, Eberth (1872) and Krebs (1871) expressed the 
opinion that the diphtheritic micrococci are the same as septic micrococci. 
Senator (1874) states that other diseases of the mouth and pharynx are 
accompanied by the same micrococci as those in diphtheria. They are 
also, he says, found in the mucus between the teeth and in normal urine, 
and the micrococci of diphtheria, do not differ in cultures from those occur- 
ring in other conditions. Billroth (1874) also dissented from the opinion 
that micrococci caused diphtheria. He made the broad statement that " the 
so-called pathogenic bacteria of diseases are positively identical with those 
found in putrefying dead tissues." Therefore the theory that micrococci 
alighting upon one of the surfaces caused diphtheria met with strong opposi- 
tion soon after it was announced, and as time went on facts and observations 
which militated against it multiplied. 

In 1877, Drs. Curtis and Satterthwaite were employed by the New York 
Health Board to investigate the etiology and pathology of diphtheria. After 

^ Virchow's Archiv, 1870. 



ETIOLOGY. 361 

many experiments tliey reported '' tliat the bacteria of diphtheritic membrane's 
do not differ in optical or chemical behavior from those found in putrescent 
but non-diphtheritic animal material." They also found that '■ scrapings from 
the upper surface of a somewhat furred tongue from a healthy person " cause, 
when inserted in the cellular tissue of the rabbit, an effect exactly similar to 
that produced by inoculations with diphtheritic membrane. Putrid Cohn's 
fluid (an aqueous solution of amnionic tartrate, potassic and calcic phosphates, 
and magnesic sulphate) also caused the same result. They were enabled, 
after many carefully-conducted experiments, to enunciate the following prop- 
ositions : " Thorough trituration of proven virulent diphtheritic membrane 
and tongue-scrapings with a high percentage of salicylic acid fails not only 
to remove, but even markedly to modify, the intensity of the infectious qual- 
ity of those substances. Hence, since salicylic acid in even a minute per- 
centage is capable of permanently suspending the vital activity of bacteria, 
the inference is that the infectious quality of diphtheritic membrane upon 
the system of the rabbit is not correlated to the vital activity of the bacteria 
present in such membrane." Therefore if, as is probable, the agent in the 
pseudo-membrane which causes the noxious effects in the inoculated rabbit 
be the same as that which causes diphtheria in man, it follows " that there is 
no theoretical ground for assuming that preventing the bacteria of a diphtheritic 
p>atch from making their way through the underlying mucous membrane icill, 
per se, prevent general diphtheritic infection of the system.''' 

These important observations and opinions, expressed by Curtis and Sat- 
terthwaite in 1877, evidently prepared the way for the theory that the bacteria 
themselves are not the cause or the infectious principle of diphtheria, but 
chemical substances or ptomaines produced by the agency of the bacteria 
may be. 

In 1882, Drs. Wood and Formad, employed by the National Board of 
Health to investigate the nature of diphtheria, after many microscopic exam- 
inations and experiments declared their belief that the micrococcus diphthe- 
riticus and m. septicus, inasmuch as they responded alike to optical, chemical, 
and vital tests, are identical. They found the same micrococcus in the 
unhealthy pus of erysipelatous cellulitis, and in 21 instances in which death 
resulted from inoculations with this pus they found the same micrococci in 
the blood of the victims. The blood of 22 cases of erysipelas was examined 
for micrococci, with the following result: "In 13 of these the organisms 
were found in the blood, whilst in the other 9 there were none. Of measles, 
29 cases were studied : in 6 only were micrococci detected, whilst in 8 cases of 
rotheln, or German measles, there were no organisms. We have also inves- 
tigated 4 cases of malignant fatal scarlet fever, in all of which we found the 
blood a few hours before death loaded with micrococci, both free, attacking 
the white corpuscles, and in zoogloea masses, and in one of which micrococci 
emboli were abundant in the kidneys. We have also studied 4 cases of " puer- 
peral fever,' probably septic metritis, in all of which micrococci existed in 
the blood before death." 

It soon became apparent to pathologists, from experiments and observa- 
tions like the above, that the so-called micrococcus diphtheriticus is not 
peculiar to diphtheria — that it occurs in all pestilential and putrid diseases, 
in decomposing animal tissues in various diseases, and even upon the tongue 
and gums in health. Hence it was necessary to look elsewhere for the cause 
of diphtheria. 

In 1883, Klebs made extended and thorough examinations of the microbes 
of diphtheria, and formed the opinion that a bacillus which he had observed 
in the pseudo-membrane and upon the inflamed tissue merited special atten- 
tion. Subsequently, Loeffier pursued the investigation, and the organism 



362 DIPHTHERIA. 

known as the Klebs-Loeffler bacillus became a prominent object of study as 
perhaps the causal agent in diphtheria. Loeffler, in the published statement 
of his investigations, remarks that all observers have found bacteria in the 
diphtheritic exudate, micrococci most frequently, existing in colonies, and 
especially abundant in superficial portions of the pseudo-membrane. At 
times bacteria have been found in the lymphatics in the vicinity of the 
inflamed tissues. Every diphtheritic patch contains many species of bacteria 
which have been cultivated, but as they have not been isolated the specific 
germ of diphtheria has not been determined. The rejection of the theory 
that micrococci are the causal agent of diphtheria, on the ground that they 
occur, presenting the same optical, chemical, and vital characteristics, in other 
distinct diseases and conditions, led to a more careful examination of other 
bacteria present in the diphtheritic exudate and upon and in the underlying 
tissues. The bacillus described by Klebs, and later by Loeffler, is motion- 
less, partly straight, partly curved, of the length of the tubercle bacillus, 
but double its thickness. It is abundant in the pseudo-membrane, but is not 
found in the blood-vessels, lymphatics, or internal organs ; so that its path- 
ogenic action must be localized on the surface. If it be the specific principle 
or germ of diphtheria, it must act by producing a ptomaine or chemical poi- 
son where it is lodged, which poison, entering the lympha^tics and blood-ves- 
sels, causes systemic infection. In some typical cases of diphtheria Loeffler 
was unable to find the bacillus — which of course militates against the theory 
that it is the specific germ — but he suggests that it might have died and been 
eliminated before the death of the patients. Such an explanation seems very 
improbable ; it is making a stubborn antagonistic fact yield to a theory ; and 
yet without such an explanation we must look for some other cause of diph- 
theria. The Klebs-Loeffler bacillus was found by Loeffler in the exudate in 
thirteen cases of diphtheria, and cultures to the twenty-fifth generation inoc- 
ulated in guinea-pigs and birds caused a whitish exudation at the point of 
inoculation. 

W. Watson Cheyne^ recognizes the importance of Klebs and Loeffler's 
researches, and thinks it probable that the micro-organism which causes 
diphtheria is a bacillus, which, lodging upon the surface of the throat, is 
propagated there. Having upon the mucous membrane a favorable nidus, 
it not only lies upon, but penetrates, the superficial portion of the mucous 
layer and causes the exudation of fibrin. The pseudo-membrane thus 
produced consists, according to Cheyne, of the fibrinous exudate and dead 
epithelial cells. As the bacilli multiply and extend, the exudate enlarges. 
Cheyne believes it probable, though demonstration is lacking, that the 
bacilli cause very poisonous ptomaines, which, entering the lymphatics 
and the blood, give rise to systemic infection and render the disease 
constitutional. 

But since the observations of Klebs, Loeffler, and Cheyne the bacillus 
which they consider the specific principle of diphtheria has been subjected 
to a more thorough examination, with the result of apparently demon- 
strating that the same bacillus occurs in non-diphtheritic cases, and even 
in healthy persons, as well as in diphtheria. Thus, Von Hofman-Wellenhof ^ 
detected this bacillus in 26 of 45 cases in various conditions of the buccal 
and faucial surfaces. He discovered it in 7 cases of diphtheria, in 3" of 
measles, in 6 of 19 cases of scarlet fever, and in 4 of 11 normal cases. In 
cultures and experiments the bacilli from different sources appeared to be 
identical. Therefore in the light of recent investigations the Klebs-Loeffler 
bacillus has no more significance as a cause of diphtheria than the micro- 
coccus of Oertel. 

^ Brit. Med. Jour. ^ Wiener med. Wochenschr.. 1888, Nos. 3 and 4. 



ETIOLOGY. 363 

Prof. Oertel, who was one of the earliest advocates of the theory of the 
microbic origin of diphtheria, and whose monograph in 1868, published in 
Ziemssens Cgdopsedia^ led to the belief in the profession that the micro- 
coccus was the cause, now admits that the theory that diphtheria is due to 
the action of bacteria, though plausible, is not proved. He has endeavored 
to elucidate the pathogeny of the disease by a careful and minute study of 
its anatomical characters.^ After an elaborate study of its histology, he 
remarks : " In the earliest-formed membranes many varieties of microbes 
can be isolated ; but practically there are two chief kinds — chain-forming 
cocci (streptococcus) and rod-shaped bacteria with rounded extremities 
(bacilli)."-^ 

Oertel remarks that in the septic form of diphtheria the cocci are abun- 
dant. In a pseudo-membrane of twelve hours' continuance micrococci 
abounded mostly on the surface, but in the fibrinous network the bacilli, 
often in colonies, preponderated. In a specimen of twenty-four hours' dura- 
tion the upper surface was full of cocci, and between them were bacilli. In 
another specimen of membrane detached after six days these two forms of 
microbes were also intermixed. As regards the tissues and organs, the micro- 
cocci and bacilli occurred upon the mucous membranes, not penetrating them 
to any great depth. They were not found in the " necrobiotic foci," nor 
were they observed in any of the sections of the kidneys which were exam- 
ined. This is a noteworthy fact, because in the examinations made between 
1865 and 1871, the results of which were published in Oertel's article in 
Ziemssens Cyclopsexlia, micrococci were found in the kidneys. He attributes 
their presence in the kidneys during this period to the fact that the cases 
under observation were septic, whereas in those recently examined septic 
infection was not common, on account, he thinks, of the employment of dis- 
infecting and antiseptic measures in place of the escharotic treatment and 
forcible detachment of the membrane, in use during the time of his former 
observations. 

The purpose of Oertel in his recent investigations has been to ascertain, 
if possible, the nature of the diphtheritic virus by a close and minute study 
of the lesions or anatomical changes which it produces. It appears from his 
examinations that the primary lesion is cell-change. " Necrobiotic pro- 
cesses" and "necrobiotic areas" commencing in the cells are observed in the 
tonsils, the mucous membrane of the fauces, uvula, epiglottis, larynx, tra- 
chea, in- the cervical submaxillary, bronchial, and mesenteric glands, in the 
spleen, and in the follicles and agminate glands in the intestines. In differ- 
ent cases these structural changes vary according to the intensity of the 
virus and the duration of its action. The morbific process extends by 
propagation through an organ or from one part to another, the virus being 
carried by the lymph-stream or blood, disintegrating products being the 
carrier. 

The following is a summary of Oertel's views in regard to the virus of 
diphtheria. They express all that is at present known of the etiology of 
this disease. The nature of the virus, says Oertel, is still obscure. It acts 
upon cells, causing their death and disintegration, and the infected particles 
convey the virus to other cells. The virus causes hyaline degeneration in 
the tissues. The hyaline degeneration in the walls of the blood-vessels 
causes them to rupture, producing hemorrhages. The unequal amount of 
hyaline change in different parts of the vascular apparatus may be attrib- 
uted to difference in resisting power or unequal exposure to the infected 

^ Die Pathogenese d. epidemischen Diphtherie, nach ihrer histologischen Beyrundung, 
Leipzig, 1887. 

2 London Lancet, March 31, 1888. 



864 DIPHTHERIA. 

blood. Secondary inflammatory processes in the lungs, heart, liver, kidneys, 
and in the central and peripheral nerve-tissues must arise from the infectious 
property of the blood circulating in them. After enumerating at length and 
with much detail the results of his examinations, Oertel expresses the opinion 
that bacterial organisms cause diphtheria, and that they produce this result 
not by their direct action, but by producing a ptomaine which infects the 
system and causes the disease to be constitutional. The microbe itself is 
mostly confined to the surface, whereas the action of the virus is " wide- 
spread and deep." The most eminent pathologists of the present time do 
not express any more positive opinions in reference to the specific principle 
or germ of diphtheria than is contained in the above summary of Oertel's 
views. 

Dr. Prudden has recently made systematic studies on a series of cases of 
diphtheria, which would seem to indicate that a streptococcus which is almost 
constantly present in the pseudo-membrane may stand in a causal relation 
to diphtheria.^ 

At a recent meeting of the London Epidemological Society, Dr. M. W. 
Taylor '^ expressed the opinion that common mould might cause diphtheria in 
persons exposed to it. The walls of a sleeping apartment became wet and 
sodden on July 12th. On the 22d a fungus appeared on the plaster, and in 
the beginning of August the three children who occupied the room, and who 
had not been exposed in any other way, so far as could be ascertained, sick- 
ened with diphtheria. The aspergillus and coprinus grew abundantly in the 
mould. In another instance, in which the child died in three days, there 
was a great development of penicilium moulds. A young man had diphthe- 
ria severely four days after cleaning out a pigeon-loft where the exuviae, 
debris, and rotten wood were covered with mould. But the theory that 
organisms which are commonly present in ordinary mould can produce diph- 
theria is improbable, for mould is common in all damp localities, where there 
is no diphtheria as well as where diphtheria is present. We shall see in our 
remarks on the propagation of diphtheria that there can be little doubt that 
pigeons and other feathered animals frequently have this disease, and in the 
instance referred to by Dr. Taylor it is probable that exuviae and debris in 
the pigeon-loft had been infected by sick pigeons. The specific principle 
must be introduced from without, but if it obtain a lodgment upon the wet 
and mouldy surface of any filthy accumulation, it may find there a nidus 
favorable for its development. We shall see that the fact appears to be 
fully established that the diphtheritic virus is frequently propagated in foul 
and damp localities, apart from the animal tissues and independently of the 
sick. We repeat, therefore, that the theory in reference to the causation of 
diphtheria which is gaining acceptance throughout the world is that it is 
produced by a microbe or microbes whose action is chiefly on the surface 
or at no great depth, and that blood-poisoning occurs mainly from a ptomaine 
or ptomaines produced by microbic agency, [n order to obtain a know- 
ledge of the ptomaine chemistry must aid microscopical investigation. 

Mode of Propagation. — No fact is better established than that diph- 
theria does not originate de 7wvo. Like the eruptive fevers, it is produced 
by the reception in or upon some part of the system of the pre-existing 
specific poison. The extreme contagiousness of diphtheria from person' to 
person is well known ; a moment's exposure to the breath of a patient, or in 
the infected room where he is under treatment or has been weeks or perhaps 
months previously, has in numberless instances communicated the disease. 
The virus adheres tenaciously to objects on which it happens to alight. The 
clothing of a patient, even when the disease is in its mildest form, his bed- 

^ See Amer. Jour. Med. ScL, 1889. ^ ^^^^ Med. Jour. 



MODE OF PROPAGATION. 365 

ding, the furniture of liis room, and the objects which he handles may for 
weeks afterward communicate the disease, and even when transported to a 
distance. A child with malignant diphtheria seen by me in consultation 
apparently contracted it by embracing a school-mate who was in the street 
for the first time after an attack of diphtheria. In another instance a child 
was for a brief period in a room where diphtheria had occurred two months 
previously, and after the usual incubative period sickened with the disease. 

Although diphtheria is often contracted in the manner mentioned above — 
that is, by exposure to a diphtheritic patient or to a room or some object 
infected by such patient — there is another mode of infection common in the 
cities. Dr. Sternberg, in his recent Lomb Prize Essay, published by the 
American Public Health Association, refers to the fact that damp, foul 
places, such as sewers, cellars, ill-ventilated spaces under floors where the 
sun never enters and where refuse collects, aiford conditions favorable for 
the development and propagation of the diphtheritic virus. The virus, what- 
ever its nature, once received, may be propagated in such a place for an 
indefinite time, and, ascending in the vapors which arise from this culture- 
bed, it is liable to communicate the disease to any one who inhales it. Thus, 
in New York City prior to 1850, although foul sewers and insanitary con- 
ditions existed, there was no diphtheria, but in the decade following 1850 
diphtheria was introduced. Its germ made its way into the sewers under- 
ground, and now wherever sewer-gas escapes into the domiciles of this city, 
it carrier with it the diphtheritic virus. The amazing vitality and power of 
propagation of the diphtheritic poison are apparent when we reflect that it 
permanently infects the filthy but constantly-flowing and constantly-renewed 
currents of the sewers of a great city. In all the wards, and apparently in 
every street, in New York City children are constantly falling sick with this 
disease, contracted by inhaling sewer-gas, which, notwithstanding " sanitary 
plumbing," often escapes from unsuspected sources, even in houses con- 
structed with all the modern improvements. It is chiefly by exposure of 
children to infected sewer-gas which ascends from this widely-extending 
underground culture-bed, and to walking cases often so mild that there is 
little or no complaint of the throat or impairment of the general health, 
that this disease is so prevalent. Most of the contagious diseases of chil- 
dren are quickly detected by characteristic symptoms or appearances which 
the most ignorant families are to a certain extent familiar with, but mild 
diphtheria possesses so few subjective symptoms that it is often not detected 
or suspected, even in intelligent families who are watchful of their children. 
Children with mild diphtheria sit among other children in the schools, in 
the city conveyances, in the churches and dispensaries, and frequently com- 
municate to those who are near them a malignant form of the disease from 
which the unfortunate victims quickly perish. The diphtheritic virus is so 
subtle, and its vitality and power of propagation so great, that when it is 
established in a sewered city it can probably never be stamped out, as cholera 
and yellow fever may be, by measures, however stringent and active, employed 
by health boards or by legislative enactments. 

Commonly, diphtheria is communicated by the inhalation of infected 
air — the inhalation of air containing the specific principle, whether derived 
directly from a patient or from some infected inanimate object, as the walls 
of a room, furniture, apparel, an article of merchandise, or sewer-gas. More 
rarely, diphtheria is communicated by direct contact with some infected solid 
substance, as a particle of the diphtheritic exudate, muco-purulent secretion 
from an infected surface, or the blood of a patient. A considerable number 
of instances has been reported in which instruments infected by use upon 
a patient, and not properly cleaned and disinfected subsequently, have been 



366 DIPHTHERIA. 

the means of communicating the disease. In these instances of communi- 
cation by direct contact the poison is received either upon one of the mucous 
surfaces or upon the skin denuded of its protecting epidermis. 

Diphtheria contracted from Animals. — Observations are accumulating which 
show that diphtheria or a disease closely resembling it occurs among animals, 
and is sometimes communicated from them to man. The feathered tribe 
especially appear to be susceptible to this disease. On the island of Skiathos, 
off the north-eastern coast of Grreece, no diphtheria had occurred during at 
least thirty years previously to 1884, according to Dr. Bild, the medical 
practitioner of the island. In that year a dozen turkeys were introduced 
from Salonica. Two of them were sick at the time, and died soon afterward ; 
the others became affected subsequently, and of the whole number seven 
died, three recovered, and two were sick at the time of the inquiry. The 
two had a pseudo-membrane upon the larynx, difficult breathing, and swell- 
ing of the glands of the neck. As further evidence that the disease was 
true diphtheria, one of the turkeys that had survived had paralysis of the 
feet. The turkeys were in a garden on the north side of the town, and the 
prevailing winds upon the island are from the north. When this sickness 
was occurring among the turkeys an epidemic of diphtheria commenced in 
the houses in proximity to the garden and spread through the town. It 
lasted five months, and of 125 cases in a population of four thousand, 36 
died. Diphtheria was from this time established upon the island, and fre- 
quent epidemics of it have occurred since.^ M Menzies ^ states that diph- 
theria is common among the poultry in Italy, in which country the flat roofs 
of the houses afford a resting-place for turkeys, fowls, pigeons, and rabbits, 
and their evacuations are carried by the rain into the cisterns and wells, A 
physician at Posilippo, near Naples, had directed his servant not to obtain 
drinking-water from the well next to his house, but from a well at a distance. 
As long as the instruction was obeyed his family was well ; but the servant, 
yielding to his indolence, finally disobeyed the command and obtained water 
from the infected well. Four of the children who drank this water soon took 
diphtheria and died. The fifth child, who did not drink the water, escaped. 
In 1878-79, Nicati of Marseilles observed cases which seemed to show that 
diphtheria is sometimes contracted from fowls.^ The Journal cle Medicine de 
Paris.^ February 19, 1888, contains an instructive paper by Dr. Delthil on the 
transmission of diphtheria from animals to man, in which a considerable 
number of apparent instances is related. Dr. F. T. Wheeler ^ states that while 
in a nesting of wild pigeons he found many sick with a pseudo-membranous 
sore throat. He dissected some of them with his pocket-knife, which he was 
obliged to throw away on account of the offensive odor. There were millions 
of pigeons in the nesting, and they were hunted and eaten by the inhabitants. 
The same year diphtheria broke out in a most malignant form, causing many 
deaths among the children. Several years previously pigeons nested in the 
same locality or near by, and fully half of the children living in the vicinity 
had diphtheria. Dr. George Turner ° states that a pigeon was brought to 
him for dissection. The whole of its windpipe was covered by pseudo-mem- 
brane, as in the croup of a child. Pigeons were inoculated in the fauces 
with this membrane, and a similar disease was produced, which extended to 
their eyes through the nostrils. An epidemic of diphtheria occurred in -the 
village of Braughing, Hertfordshire, England, the first cases appearing on a 
farm where the fowls were dying of a disease similar to that in the pigeon ; 
and on other farms where diphtheria appeared it was preceded by a similar 

1 Bulletin Med., January 22, 1888. ^ Theds, Paris, 1881. 

^ Marseille Med., 1879, p. 105. * American Practitioner and Nevjs. 

^ Journal of Laryngology and Rhinology. 



MODE OF PROPAGATION. 367 

disease in the fowls. Dr. Turner also mentions several other epidemics of 
diphtheria in different localities where the poultry, turkeys, pigeons, and in 
one locality the pheasants, perished of a disease attended by this membranous 
exudation. At Tougham a man bought a chicken at a low price, as it was 
affected by the prevailing disease, and cared for it at his home. Soon after 
diphtheria broke out in his family, and this case was the first in the village. 
Instances are also cited by Dr. Turner showing that cats, sheep, and pigs 
have suffered from a severe disease of the throat, probably diphtheritic, in 
several localities where diphtheria was prevailing among children. 

According to the observations of various experimenters, diphtheria can be 
transmitted from man to animals ; and, if this be true, it seems probable that 
it can likewise be transmitted from animals to man. Trendelenburg inoculated 
68 rabbits, introducing diphtheritic pseudo-membrane into the trachea through 
an artificial opening: 11 of the rabbits died with the symptoms and appear- 
ances of diphtheria. In control experiments he introduced various foreign 
bodies into the larynx of rabbits, and was unable to produce any results or 
lesions resembling those in diphtheria. Oertel performed 12 similar experi- 
ments, and 5 of the rabbits died after the production of pseudo-membranes. 
Zahn, Gerhard, Labadie-Lagrave, Francotte, and Yulpian obtained similar 
results from their experiments. Such observations and experiments render 
it probable that genuine diphtheria, equally fatal and attended by the same 
anatomical characters and symptoms as in man, does occur in birds, whether 
wild or domesticated, and in certain quadrupeds, as the rabbit. Nevertheless, 
we should add that certain eminent pathologists, among whom we may men- 
tion the honored name of Yirchow, have doubted the identity of animal and 
human diphtheria. With our present light on the subject it is evident that, 
since our relations to the domestic animals are so close, if they are sick with 
any disease resembling diphtheria the same precautionary measures should 
be taken to prevent infection of the family as in human diphtheria. 

Mr. Cole, a veterinary surgeon of Hinckley, Australia, published in the 
Australian Veterinary Journal^ February, 1882, copied into the New York 
Medical Record., the account of an epidemic of diphtheria that was appa- 
rently traced to the milk obtained from a diseased cow. In 1879, Mr. W. 
H. Power, health inspector, investigated an outbreak of diphtheria, and 
believed that he traced it to the milk-supply. The cows which furnished 
the milk that seemed to communicate the disease had what the veterinary 
surgeons designate" garget," or "infectious mammitis."^ Another similar 
history of an epidemic is related by the same journal that published Mr. 
Power's report. Prof. Damnian of the Hanover Veterinary School reported 
in the Deutsche Zeitschrift fur Tliiermedicin., 1877, an epidemic of what seemed 
to be diphtheria in calves. He directed the attendant to make applications to 
the mouths and throats of the affected calves. This was on April 29. On 
May 5 the attendant became sick, complained of his throat, and was confined 
to bed. A pseudo-membrane appeared on his tonsils, which were highly 
inflamed ; he had fever and enlargement of both the submaxillary and cer- 
vical glands. A dairy-maid who now took charge of the calves also had a 
similar but less severe attack. Milk is a culture-medium of various microbes, 
and that it may be the medium of communication of diphtheria as well as of 
scarlet fever seems probable. 

The fact that the diphtheritic virus may be conveyed long distances with- 
out losing its virulence is now admitted from the many observations that have 
been made. Prof. C. W. Earle of Chicago read before the Ninth Interna- 
tional Medical Congress an interesting statistical paper on the occurrence of 
diphtheria, often severe and fatal, in salubrious rural localities, free from 

' Med. Times and Gaz., Jan., 1879. 



368 



DIPHTHERIA. 



sewage-gas and water-pollution, in the newly-settled and mountainous States 
and Territories of the North-west. Dr. Earle's statistics render it probable 
that the diphtheritic infection is transported long distances to these localities, 
being carried in articles of clothing and merchandise. The well-known tena- 
cious adherence of the virus to objects renders it highly important that 
thorough disinfection should be employed before articles are removed from 
an infected room. 

Age. — Trousseau has said that diphtheria does not spare any age, but is 
most common between the ages of two and five or six years. Guersant believes 
that the age of greatest frequency is between the second and seventh years, 
and Barthez and Rilliet agree with Guersant. Bouilion-Lagrange in 63 cases 
occurring in one epidemic treated — 



Under 2 years 14 cases. 

From 2 to 6 " 18 " 

6 to 12 " 10 . " 

" 12 to 18 " 9 '' 



From 1 8 to 30 years 15 cases. 

" 30 to 40 " 4 " 

" 40 to 50 " 1 case. 

Above 50 " ....... 2 cases. 



According to M. Barthez, in Sainte-Eugenie Hospital during twenty years 
the ages of the diphtheritic patients Avere as follows, adults being excluded 
from this institution : 



Under 1 year 81 cases. 

From 1 to 2 years 314 '' 

" 2 to 3 " 319 " 

" 3 to 4 " 292 " 

'' 4 to 5 " 200 " 

" 5 to 6 " 103 '•' 



From 6 to 7 years 59 cases. 

7 to 8 " 36 " 

8 to 9 " 24 " 

9 to 15 " 82 " 

" 15 to 17 " 2 " 



Louis has shown that diphtheria may occur at an advanced age, but it 
is rare over the age of forty years, and very rare after the age of sixty years. 

Oertel says, " In the first half year the infant organism seems to be not 
at all susceptible to the disease." As in scarlet fever, so in diphtheria, cases 
are infrequent under the age of six months, but a considerable number of 
cases are on record showing that it does occur even in the newly-born. Dr. 
A. Jacobi has collated the following cases : A child of fourteen days treated 
by Tigri, one of fifteen days by Bretonneau, one of seventeen days by Bed- 
nar, one of eight days by Bouchut, one of seven days by Weikert, several 
cases by Parrot, and eighteen cases observed by Siredey in the Hopital Lari- 
boisiere in the spring of 1877. Dr. Jacobi adds : " I have met with three 
cases of diphtheria of the pharynx and larynx in the newly-born myself. 
One of these became sick on the ninth day after birth, and died on the thir- 
teenth day ; the other died on the sixteenth day after birth ; the third was 
taken when seven days old, and died on the ninth day."^ 

Certain physicians having charge of maternity wards have observed a dis- 
ease occurring in newly-born infants which bears some resemblance to diph- 
theria, but which, if it be true diphtheria, presents anomalous features. 
Thus, Dr. W. S. Bigelow reports in the Boi^ton Medical and Surgical Journal 
for March 11, 1875, 10 cases occurring between September and December, 
1873, in the Boston Lying-in Asylum, all fatal but 2. The prominent symp- 
toms and anatomical characters were dark hue of skin, haematuria, pseudo- 
membranous exudation upon certain mucous surfaces, dark-green stools, 
spleen enlarged and dark, kidneys engorged, in some of the cases effusion 
of blood into the pelves of the kidneys and along the urinary tract. Dr. 
Bigelow refers to what appear to have been similar cases in one of the 

^ Treatise on Diphtheria, New York, 1880. 



AGE. 369 

European asylums. The presence of pseudo-membranous exudations on the 
mucous surfaces, and renal casts, raises the suspicion that the disease which 
gave such strong evidence of infectiousness was diphtheria. That, so far as 
appears from the records, the mothers remained well, does not preclude the 
belief that the disease of these infants had a diphtheritic origin ; for in cases 
which we will presently relate the mothers with one exception remained well, 
although their infants a few" days old undoubtedl}^ had diphtheria. 

A case in some respects similar to those observed by Dr. Bigelow came 
under my notice. 31alignant diphtheria occurred in a family in West Fifty- 
third street, Xew York, in October, 1880. The patient, a boy of ten years, 
died, and the remaining two children, as soon as the nature of the malady 
was apparent, were sent from the house. Nevertheless, one of those pre- 
cisely seven days after the removal was attacked by diphtheria of the hemor- 
rhagic form, and died in less than a week. Blood escaped from the nostrils, 
fauces, under the skin in numerous places, causing purpuric spots, and from 
the kidneys or urinary' tract, causing haematuria. The mother, who was at 
this time in the sixth month of pregnancy, continued greath^ depressed by 
the occurrence, although her general health seemed to be good. She had 
been in constant attendance upon her children. Her infant, born three 
months subsequently to the occurrence of diphtheria in her family (Febru- 
ary 6, 1881), was well developed, but it presented a similar hemorrhagic 
cachexia to that in the second case of diphtheria. Blood escaped from the 
vessels under the skin, causing blotches and prominences, and from the 
mucous surfaces. The bleeding was persistent and copious from the umbil- 
icus, so that death occurred in less than a week. The diphtheritic virus is 
subtle and penetrating, causing the specific inflammation in the uterine walls 
of the parturient woman even when her fauces are not affected. Neverthe- 
less, whether diphtheria sustains a causal relation to cases like the above is 
uncertain, and can be determined only by more numerous observations. 

The admitted infrequency of diphtheria in the newly-born, and the state- 
ment by some writers that they have an immunity from it, induce me to relate 
the following cases, in which the diagnosis of diphtheria was established 
beyond doubt by carefully-conducted necropsies and microscopic examina- 
tions : 

The New York Foundling Asylum at Sixty-First street and Tenth avenue 
has during the twenty-three years of its existence been remarkably free from 
contagious and infectious maladies, but from September 1, 1887, to April, 
1888, an epidemic of diphtheria occurred in the institution. During this 
time five new-born infants had diphtheria, the pseudo-membrane appearing 
in its usual situation on the pharyngeal, nasal, and laryngo-tracheal surfaces, 
and in one of the cases also lining the oesophagus. Two of these infants 
(Cases 1 and 2) had umbilical phlegmons in addition to diphtheria, and their 
cases are related in our remarks on Sepsis of the New-born, pages 137 and 
138, to which the reader is referred. 

Case 3. — Olivia G , born January 8th, and wet-nursed by her mother, was 

apparently well until January 14th, when she became restless. On the 15th, 
when she was seven days old, she was carefully examined, and diphtheritic 
patches Avere observed on the faucial surface ; rectal temperature 100° F, respi- 
ration 36, pulse 120. She had commencing nasal catarrh, with the usual infil- 
tration and muco-purulent discharge, which so obstructed the nostrils that she 
could not take the breast, and she was fed with the mother's milk from a spoon. 
Probably patches of pseudo-membrane were present in the nostrils, but none 
were observed upon the visible parts until the 17th, when the characteristic pel- 
licle occluded the right nostril. Daily notes of the case have been preserved, 
and the symptoms as regards temperature, respiration, pulse, and the cyanosis 
bore a close resemblance to those in the above cases. Death occurred on the 
24 



370 DIPHTHERIA. 

18th. At the autopsy, in addition to the diphtheritic patches already mentioned 
occurring upon the faucial and nasal surfaces, a pseudo-membrane was found 
covering the larynx, trachea, and cesophagus to within one inch of the stomach. 
No notable change was observed in the appearance of the internal organs, with 
the exception of numerous points of extravasation in the lungs. 

Case 4. — Victor K , born December 7, 1887, appeared to be in usual health 

until January 13th, when at the age of thirty-seven days the mother called the 
attention of the resident physician. Dr. Davis, to him, as he appeared to be seri- 
ously sick. His temperature was 103.2° F., and his breathing indicated acute 
nasal catarrh. On the following day, the 14th, the grayish-white exudate of 
diphtheria was observed covering the left side of the uvula. The inability to 
remove it by the brush or washing demonstrated its diphtheritic nature. His 
subsequent history resembled those given above. Death occurred on the 15th. 
At the autopsy no pseudo-membrane was observed except that already described. 

Case 5. — Vincent B , born December 31, 1887, was well until January 17, 

1888, when symjDtoms of a catarrhal nature attracted attention. The nostrils 
seemed to be unaffected, but upon the posterior portion of the fauces was a gray- 
ish-white patch of the usual diphtheritic appearance. By antiseptic and solvent 
inhalation this pellicle became smaller, and on the 21st had disappeared. The 
infant recovered. 

Diphtheria of the newly-born is sometimes wrongly diagnosticated. Tlius, 
in the New York Foundling Asylum, where diphtheria was occurring, the 
tonsils of an infant a few days after birth presented a grayish-white appear- 
ance, suspected to be diphtheritic. After its death the curator, Dr. Northrup, 
discovered a pultaceous state of the surface of the tonsils, but no pseudo- 
membrane. The disease was apparently not diphtheritic ; but, as regards 
the cases related above, diphtheria was undoubtedly present in the first three, 
and there can be little doubt that this was also the disease in the remaining 
two. The occurrence of these cases in so short a time in a small maternity 
service shows that under certain circumstances the newly-born infant exhibits 
considerable susceptibility to diphtheria. 

Incubation. — The duration of the incubative stage in experimental inoc- 
ulation is short, varying from twelve hours to three days. In Trendelen- 
burg's experiments the incubation was mostly from one to three days ; in 
Lagrave's, about twenty hours. In Duchamp's inoculations the animals 
died after forty-eight hours with the larynx and trachea, upon which the 
infectious material was applied, covered with pseudo-membrane. Oertel says 
that the rabbits upon which he experimented by inoculation of the muscles 
perished in from thirty to thirty-six hours, rarely after forty-two hours, the 
disease-process extending rapidly to neighboring tissues. When diphtheria 
is contracted by a child upon an excoriated or wounded surface, as after cir- 
cumcision, ablation of the tonsils, or upon a leech-bite or a burn, the incuba- 
tive period is short, but it may be as long as four days. Thus, the British 
Medical Journal, and subsequently the Archives of Pediatrics, published the 
following interesting case, contributed by Mr. Phillips : A few hours after 
the performance of tracheotomy for diphtheritic croup the same instruments 
were employed for performing circumcision in a child of eighteen months. 
Four days later a false membrane appeared upon the wound of the prepuce, 
which by the following day had extended over the glans, with much oedema 
of the prepuce and retention of urine. 

When diphtheria is contracted in the usual manner — that is, by -the 
inspiration of air containing the specific principle — the period of incubation 
appears to be on the average somewhat longer than when it is communicated 
by direct contact. My observations lead me to believe that when the incu- 
bative period is short the disease is likely to be severe, and mild when the 
incubative period is long. I was enabled to ascertain Very nearly the incu- 
bative period in the following cases : A boy of nine years was in the same 



NATURE. 371; 

room about one hour on Saturday witli a child who had fatal diphtheria. 
On the following Tuesday, without any other exposure, he sickened with a 

severe and fatal form of the disease. Mrs. E assisted in nursing a severe 

case of diphtheria from November 11 to 13, 1874, after which she returned 
home, several blocks away. On the evening of the 15th she complained of 
sore throat, and on the following day the diphtheritic pseudo-membrane was 
observed upon her tonsils. On the 19th the exudation had disappeared and 
she was convalescent. On the 20th her sister, who resided with her, and 
who had not been elsewhere exposed, was also attacked. The only other 
case in the family, a boy, sickened with diphtheria on December 2d. In the 
first of these cases the incubative period seems to have been from two to 
four days, while in the last it was longer. In April, 1876, a little girl died 
of malignant diphth&ria in West Forty-first street, New York City. Her 
sister, aged one year, remained with her from April 14th to 17th, when she 
was removed to a distant part of the city and placed in a family where there 
had been no diphtheria. On April 24th, seven days after her removal, this 
infant was observed to be feverish, and on the following day, when I was 
called to examine her, the characteristic diphtheritic patch had begun to 
form over the left tonsil. In April, 1875, two sisters, aged five and seven 
years, resided with their parents in a boarding-house in West Twenty-second 
street. A playmate in the same house had symptoms which were supposed 
to be due to a cold, but which were diphtheritic, when one night severe lar- 
yngitis occurred and ended fatally the following day. The physician who 
had been summoned diagnosticated diphtheria, and the two sisters were 
immediately removed to a hotel. Seven days subsequently diphtheria com- 
menced in the older child. The younger sister was then removed to a dis- 
tant part of the same hotel, but six or seven days later she also was attacked. 
Sanne says that in 98 cases the incubative period appears to have been as 
follows : 

From 1 to 2 davs 7 cases. ' From 13 to 15 davs 6 cases. 

" 2 to 8 '' 48 '' j " 15 to 20 "" 14 " 

" 8 to 18 " 23 '' 1 

But diphtheria is so insidious and the modes of exposure so many that 
in some of the cases of an apparently long incubation there may have been 
a second exposure. The above statistics show that the incubative period 
varies, but is most freciuently from two to eight days. 

Nature. — Diphtheria resembles scarlet fever in certain particulars : in 
its incubative period, varying from two to eight days, with occasional cases 
outside of these limits ; in its variability of type, from a very mild to a 
malignant form ; in the common seat of its inflammations — to wit, upon the 
fauces and nasal passages ; in the profound prostration and blood-poisoning in 
the graver cases ; and in the frequent occurrence of nephritis as a compli- 
cation or sequel. Lt resembles both scarlet fever and smallpox in the fact 
that it has the twofold mode of communication through the air and by con- 
tact or inoculation. It resembles erysipelas in the variableness of its dura- 
tion, and in the fact that one attack does not prevent the occurrence of 
another. In its etiology it resembles typhoid fever ; for it is not only com- 
municable from person to person, but it is communicated by foul exhalations, 
as sewer-gas, in which the poison lurks. But while there are certain resem- 
blances, it is distinguished from all these infectious diseases by marked pecu- 
liarities. 

Diphtheria is primary or secondary. The secondary form most frequent- 
ly occurs during epidemics of the other infectious diseases and as a com- 



372 DIPHTHERIA. ' 

plication of them. Those infectious maladies which are accompanied by 
inflammation of the fauces and air-passages are most liable to this complica- 
tion if they occur in a locality where diphtheria prevails. In these instances 
of secondary diphtheria the diphtheritic inflammation supervenes upon the 
inflammations which pertain to the primary diseases. Scarlet fever beyond 
any other malady appears to furnish the conditions which are most favorable 
for the occurrence of diphtheria in the latter part of the first week or in the 
second week of its continuance. If scarlet fever and diphtheria be epidemic 
in the same locality, not infrequently toward the close of the first week of the 
former disease a sudden aggravation of symptoms occurs, and the cause is 
soon rendered apparent by the appearance of the diphtheritic exudate upon 
the faucial surface, usually upon its tonsillar portion. The discrimination 
under these circumstances of the diphtheritic inflammation from a severe 
scarlatinous angina is to be carefully made, and is sometimes not easy, for 
the scarlatinous inflammation, if intense, occasionally becomes gangrenous, 
so as to present an appearance resembling that of a pseudo-membrane. The 
other infectious maladies which are most liable to the diphtheritic com- 
plication are measles, variola, whooping cough, and typhoid fever, the 
catarrhal inflammation of these diseases changing to a pseudo-membranous 
inflammation. 

It is an interesting and important fact that when diphtheria is contracted 
by a person having inflammation of one of the surfaces, the specific inflam- 
mation with the pseudo-membrane usually occurs upon the part which is 
already inflamed. A catarrhal inflammation, however produced, is liable 
under the influence of the virus to become diphtheritic and pseudo-mem- 
branous. Thus, at one time diphtheria entered the eye ward of the New 
York Foundling Asylum, and three children who were under treatment for 
inflammation of the eyelids were attacked by diphtheritic conjunctivitis, 
exemplifying the remark by Billroth, that " catarrhal conjunctivitis, which 
is so very common, may become diphtheritic."^ Catarrhal inflammation 
from abrasions, burns, wounds however produced, are liable to be attacked 
by the diphtheritic inflammation and become covered with the pseudo-mem- 
brane. In Paris, where diphtheria is very prevalent, the circumcised prepuce 
has so often become the seat of the diphtheritic exudate that the distin- 
guished surgeon Saint-Germain considers this fact a strong argument in 
favor of stretching, which he practises instead of circumcision. He also 
for the same reason among others recommends the treatment of enlarged 
tonsils by galvano-cautery instead of excision. However, in one instance in 
which I was employing dilatation of the prepuce, and in which the mucous 
membrane may have been injured by the operation, a severe diphtheritic 
inflammation set in on the following day, and extended from the tip of the 
prepuce to the body, with intense redness and swelling. The tonsils at the 
same time were inflamed and covered with the membranous exudation. 
Although severely sick, the patient recovered in a few days. 

This general fact in regard to the nature of diphtheria and its mode of 
manifestation — to wit, that in one affected by it the diphtheritic inflammations 
appear by preference upon such surfaces as are already inflamed — has an 
important practical bearing. In frequent instances during epidemics of diph- 
theria inflammations which physicians of experience believe to be simple or 
catarrhal, and have diagnosticated as such to their friends, are seen in a few 
days to be diphtheritic. The most serious error of this kind, if it be one, is 
to diagnosticate and treat diphtheritic croup as a simple or catarrhal laryngitis 
until the increasing dyspnoea reveals the true nature of the disease. This 
experience always places the physician in an unfavorable light. But is it 
^ Encyc. Pathol., translated, p. 267. 



NATURE. 373 

not probable that in a certain proportion of siicb cases the disease was at first 
a simple catarrhal inflammation, and that it became diphtheritic during its 
progress, just as scarlatinous angina or rubeolous laryngitis becomes a diph- 
theritic inflammation in those who contract diphtheria ? 

The frequent occurrence of diphtheria in all civilized countries during the 
last thirty years, and the great mortality which attends it, have awakened an 
interest in this malady which has led to a careful study of its causes and 
nature. At first these inquiries were chiefly clinical, but in later years micro- 
scopic examinations and experiments on animals have furnished important aid 
in elucidating the nature of the disease. The importance of these micro- 
scopic examinations and experiments cannot be overestimated. In connection 
with clinical observations, they render highl}^ probable the theory which has 
been stated above, that diphtheria is produced by micro-organisms, which, 
coming in contact with the mucous membrane or the cuticle deprived of its 
epidermis, adhere to it, and, multiplying rapidl}^ act as an irritant and pro- 
duce the characteristic inflammation ; and the fact that since antiseptic treat- 
ment has come into general use microbes, in at least many instances, have 
not been found in the blood-vessels, lymphatics, or internal organs in those 
who have died of diphtheria, has led to the belief, as we have already 
remarked under the head of Etiology, that the systemic poisoning occurs 
through the agency of chemical products or ptomaines, which, produced by 
microbic action, are absorbed into the system. Whether this theory be 
entirely true or not will be determined by future investigations. If true, 
it of course establishes the fact that diphtheria is primarily a local disease. 
Whether it is primarily local or constitutional has been and is still much dis- 
cussed. It is suSicient for the wants or purposes of the practising physician 
to be assured that in all cases, unless of the mildest type, diphtheria, if not 
primarily constitutional, is attended by systemic blood-poisoning very early, 
even on the first day, so that in all cases of average severity constitutional as 
well as local treatment is required. The following facts indicate the early 
blood-poisoning in diphtheria : 

1. It is a law in pathology that those diseases which have or may have a 
long incubative period — say of a week or more — are constitutional. 

2. Another fact which indicates primary blood-poisoning in diphtheria 
is observed in certain cases — namely, the occurrence of severe constitutional 
symptoms for a longer or shorter time, perhaps for half a day, before the 
appearance of the usual inflammation. Thus, a girl of five years, having 
malignant diphtheria, whom I saw in consultation, was carefully examined 
on the first day of her sickness by the attending physician, and, although 
he closely inspected the fauces, there was no appearance which indicated the 
nature of the malady till the subsequent day. In such cases, a suflicient 
number of which I have observed, there is likely to be complaint of soreness 
of the throat or difiiculty in swallowing almost from the beginning of the 
general symptoms, but the pain and tenderness seem to be in the deeper tis- 
sues of the neck. - 

Again, treatment of the inflammations by the most reliable and efiicient 
antiseptics and disinfectants which we possess, commenced at the earliest 
possible moment and repeated at short intervals, does not prevent the occur- 
rence of indubitable symptoms of blood-poisoning in cases of a severe type. 
Thus, I have treated every portion of the inflamed surface, so far as it was 
accessible, every second or third hour with carbolic acid and other disinfect- 
ants almost from the very commencement of diphtheria, and so thoroughly 
that any vegetable or animal poison with which the remedies had come in 
contact would probably have been destroyed or rendered inert, and yet, except 
in mild cases, symptoms of diphtheritic blood-poisoning have occurred, and 



374 DIPHTHERIA. 

as early and uniformly as if less energetic local measures had been employed. 
While, therefore, I do not fail to recommend local treatment as calculated to 
diminish septic poisoning and relieve the inflammations, I have lost con- 
fidence in it as a means of preventing the entrance of the diphtheritic poison 
into the blood. Its powerlessness to prevent contamination of the blood by 
the diphtheritic virus is an additional evidence that this contamination occurs 
early. 

3. The quich succumbing of the system in certain malignant cases is evi- 
dently due to diphtheritic toxaemia. We sometimes observe a fatal result on 
the second, third, or fourth day, without any dyspnoea or sufficient laryngitis 
to compromise life. Cases of this kind, terminating fatally even in the first 
clay, have been reported. The system is suddenly overpowered by the poison, 
struck down, as it were, by the profound blood-change, while the inflamma- 
tions are still in their incipiency. 

4. Important evidence of the constitutional nature of diphtheria is aff"orded 
also by the state of the kidneys. No internal organs are so often afl"ected in 
diphtheria as the kidneys, and, on account of their location and anatomical 
relation, it is evident that the poison first passes through the system before it 
reaches them. Any clinical or anatomical fact, therefore, which indicates 
that the diphtheritic virus has reached and afl"ected the kidneys afl'ords proof 
that it has penetrated the system and poisoned the blood. Now, the occur- 
rence of albumen, with granular or hyaline casts, in the urine, in cases unat- 
tended by dyspnoea, aff"ords proof of nephritis caused by the action of the 
poison on the kidneys. 

Sir John Rose Cormack of Paris, in a series of interesting and useful 
papers relating to diphtheria published in the Edinburgh Medical Journal 
during 1876, states that albuminuria, and of course the nephritis on which 
it depends, sometimes begin as early as the first day. My observations con- 
firm this statement, as in the following cases : 

Case 1. — L. McD , aged three years, was first visited by me on February 

29, 1876. I learned from the parents that she had been feverish during the pre- 
ceding forty-eight hours and her urine very scanty. A moment's examination 
w\as sufficient to show that the case was one of malignant diphtheria, for the fauces 
were already nearly covered by the diphtheritic pellicle ; the temperature was 
1031° F,, and the pulse HO. The skin was hot and dry, and there was moderate 
swelling under the ears and a muco-purulent discharge from the nostrils. On 
account of the scantiness of the urine, the amount not exceeding f5iv-v daily, it 
was impossible to obtain sufficient for examination till the following day. It was 
then found to have a specific gravity of 1032, to contain a deposit of urates and 
hyaline and granular casts, a diminished amount of urea, and a large quantity of 
albumen. It can hardly be doubted, from the scantiness of the urine and the 
large amount of albumen found when the urine was first examined, that albu- 
minuria had been present on the first day. 

Case 2. — The following was a similar case : K , aged four years, living in 

West Thirty-sixth street, was visited by me in consultation on January 29, 1875. 
Her sickness had also continued forty-eight hours ; her fauces were swollen and 
covered with the diphtheritic pellicle, which was dark and offensive ; respiration 
guttural; pulse 120; temperature 101° F. ; she had a free discharge from each 
nostril; urine scanty, its specific gravity 1030; it contained a small amount of 
albumen with casts, aud a large amount of urates, with no apparent diminution 
of the urea. Death occurred on the fourth day. 

In such severe cases, in which albumen and casts are found in the urine 
at the first visit of the physician, there can be little doubt that the nephritis 
begins nearly or quite as early as the pharyngitis ; and therefore, since poison- 
ing of the blood must antedate the renal disease, diphtheria aff"ects the system 
very early, probably from the occurrence of the first symptoms. 



NATURE. 375 

Again, there are cases, though not frequent — three I can recall to mind 
during the last two years in my practice — in which the external manifesta- 
tions of diphtheria are very mild, even insignificant, and quickly cured, but 
in which the kidneys are early and severely affected. The occurrence of such 
cases is best explained on the supposition of an early and profound blood- 
change. The following are histories of two of the cases alluded to : 

The house 229 West Nineteenth street, New York, is an old wooden struc- 
ture, and the family which has occupied it during the last five years has been 
three times visited by diphtheria, the first case, that of the oldest child, 
proving fatal. In February, 1876. one of the children had diphtheria in a 
moderately severe form. He recovered, and after my visits had been dis- 
continued his sister, aged six years, who had had scarlet fever when eighteen 
months old, became feverish and complained of her throat. No rash appeared 
on her skin, and there was apparently no coryza. Inspection of the fauces 
by the parents revealed a small diphtheritic patch over each tonsil. Although 
diphtheria was so frightful a malady to this family from their past experience, 
the case seemed so mild that the parents treated it without medical attend- 
ance by the remedies which had been employed for the boy. A mixture of 
carbolic acid, subsulphate of iron, and glycerin was applied to the fauces 
every third hour, sufficiently often, apparently, to destroy all bacteria or 
other vegetable or animal organisms with which it might have come in con- 
tact, and within two or three days the inflammation of the throat seemed to 
the parents to be cured. Nevertheless, with this insignificant inflammation 
of the fauces, so quickly subdued, and with no other apparent inflammation 
of the mucous surfaces, there was severe internal disease going on as the 
result of the general infection. The child did not regain her former appetite ; 
she had increasing pallor, although able to play about the house ; and finally, 
in the the third week, when I was called to see her, slight oedema of the face 
and limbs was observed. Her urine, which was scanty, was found to contain 
pus and blood-corpuscles, albumen, and granular casts, and nearly two months 
elapsed before, under treatment, it became normal and her health was restored. 

The second case occurred in January, 1878, in West Fifty-first street. A 
boy aged six years, in a family where diphtheria was occurring, had slight 
sore throat, which abated in two or three days. It was attended by little or 
no exudation, and would not have been considered diphtheritic except for the 
circumstances in which it occurred and the subsequent history. Still, the 
boy remained ill and fretful, and four days subsequently his urine was found 
to be scanty and very albuminous ; and three days later death occurred, pre- 
ceded by total suppression of urine. The last urine passed, which was not 
more than a teaspoonful, became nearly semi-solid by heat. There had been 
no scarlet fever in the family. 

Cases like the above, in which there is an early and profound systemic 
infection, with but slight evidence of lodgment of the virus upon the faucial 
or other exposed surface, are interesting as showing the constitutional nature 
of the malady, even when the symptoms and visible lesions have extreme 
mildness. Certain clinical observations, therefore, lend support to the theory 
that diphtheria, even if it be in most instances local at first, is in some cases 
systemic from its commencement, and seem to justify the remark made by 
Dr. A. Jacobi, that probably in some instances the diphtheritic virus enters 
the system through the lungs — -a supposition which demands consideration, 
notwithstanding the fact that many pathologists now believe that the specific 
germ acts only upon the surface. Whether diphtheria be always local in 
its commencement or sometimes systemic, it answers the wants of the prac- 



376 DIPHTHERIA. 

titioner to be assured that in cases of a severe type diphtheria is systemic 
at so early a period that constitutional remedies are required at the first 
visit. He will be the most successful practitioner who fully recognizes the 
fact that he has to deal with a malady which has both a local and a systemic 
character. 

Diagnosis. — It is very important that the diagnosis of a case of diph- 
theria be early made, so that proper remedial measures may be employed at 
the beginning, as well as measures designed to prevent propagation. In a 
large proportion of cases the diagnosis is easy after diphtheria has continued 
twenty-four hours, since, in addition to the fever and pain in swallowing, the 
characteristic grayish-white pellicle has begun to form on one or both tonsils. 
Under such circumstances the nature of the malady is apparent on inspecting 
the fauces. But many cases are not so quickly and readily diagnosticated, 
even by experienced physicians. The diagnosis is uncertain, and is postponed 
until two or more days have elapsed. One reason, of failure to diagnosticate 
early is the fact that many patients, even those old enough to express their 
sensations, do not complain of the throat. I have many times been informed 
by parents or nurses that there was no need of examining the fauces, as there 
was no complaint of pain in the throat, and yet on examination have observed 
unequivocal evidence of diphtheria. A physician practising in a locality 
where diphtheria is prevailing should at his first visit inspect the fauces of a 
child to whom he is summoned, especially if there be fever, and he will often 
discover evidences of diphtheria which without such examination would not 
have been detected. 

When diphtheria has continued from twelve to twenty-four hours, external 
examination of the neck usually reveals some tenderness as well as fulness in 
the tonsillar regions, and the enlargement of the tonsils can be readily detected 
on palpation ; but in some instances the tenderness and swelling are so slight 
as to be scarcely appreciable. In not a few cases it is impossible to make a 
positive diagnosis until the disease has been under observation some days and 
its progress and character have been carefully noted, the difiiculty in diagno- 
sis arising from the fact that the membranous exudate is concealed from view. 
Thus, in nasal diphtheria the pseudo-membrane may be located upon the supe- 
rior and posterior portions of the Schneiderian membrane, and therefore be 
invisible, while the anterior and visible portions of the nares and the faucial 
surface are hypersemic and secreting muco-pus in abundance, but are free 
from the pseudo-membranous exudate. The pseudo-membrane may, and 
probably will, appear upon visible parts before the disease terminates, but 
not early enough to establish a diagnosis in the first days of the sickness. 
Occasionally in the milder forms of pharyngeal diphtheria membranous 
patches occur in the depressions of the faucial surface, and are not visible 
on cursory inspection. They are brought into view when the patient coughs 
or by firm external pressure upon the side of the neck, which elevates the 
depressed surfaces. 

In laryngo-tracheal diphtheria diagnosis is not infrequently delayed in a 
similar manner. The child, without known exposure to the diphtheritic virus, 
becomes hoarse, and the hoarseness with fever increases. The fauces show the 
characteristics of catarrhal inflammation, and the nostrils are not affected or 
are affected but slightly. The diagnosis between catarrhal croup, non-specific 
membranous croup, and diphtheritic croup is uncertain. The patient may 
die without any visible pseudo-membrane unless the laryngoscope be used, 
and without a diagnosis except the general one of croup. The occurrence of 
albuminuria with casts may enable us to make the probable diagnosis of diph- 
theria, and this opinion may be confirmed by the contemporaneous or subse- 
quent occurrence of diphtheria in other members of the family ; but in other 



DIAGNOSIS. 377 

instances no such aid is obtained, and the nature of the attack continues to 
be a matter of probability only. Such are some of the hindrances in the 
way of accurate diagnosis. 

The following is a resume of the characteristics of the white, grayish, or 
grayish-white products of disease which occur on the faucial surface and which 
are liable to be mistaken for the pseudo-membrane of diphtheria. Let us first 
consider the characteristics of the diphtheritic exudate. It is deeply set in 
the mucous membrane, penetrating it and being incorporated with it. It 
consists of necrosed mucous tissue and firm fibrinous material exuded from 
the minute vessels, and it cannot be detached from the faucial surface, except 
at an advanced stage of the disease, without producing hemorrhage. It is 
surrounded b}' inflamed and swollen mucous membrane as the crystal of a 
watch is surrounded by the rim. Compare these characteristics of the diph- 
theritic pseudo-membrane with the products of other and distinct diseases of 
the pharynx. First, follicular tonsillitis. This is a common disease. In 
New York, and probably elsewhere, it frequently extends through families as 
if contagious, all or most of the children being affected by it. It is attended 
by fever and dysphagia. It has no marked premonitory symptoms, unless of 
very brief duration, and commences suddenly, like diphtheria, with headache, 
chilliness, heat of surface, the temperature often rising to 103° F., languor, 
and frequently pain in the back and extremities. The dysphagia attracts 
attention to the fauces, the surface of which is seen to be hypergemic, espe- 
cially its tonsillar portion. In a few hours a whitish material exudes from 
the crypts of the tonsils, consisting of the secretion of the crypts and epi- 
thelial cells, and forming rounded masses of the size of a small pin's head. 
The secretion, occurring as small, rounded, salient masses distinct from one 
another, is distinguished by its appearance from the diphtheritic pseudo-mem- 
brane, which at first is a thin, pellucid film, becoming thicker subsequently. 
Consisting simply of epithelial cells held together by the secretion, these 
small rounded masses are quickly detached by the swab or brush, when they 
are found to be friable, readily crushed between the thumb and fingers, and 
having a fetid odor. If two or more of them happen to unite, forming an 
appearance like that of the diphtheritic membrane, they still present the 
same physical characters, and are readily detached from the tonsillar surface 
without hemorrhage. This peculiar secretion of follicular tonsillitis is usu- 
ally limited to the tonsillar portion of the pharynx, and is of short duration, 
ceasing to appear after two or three days. The inflammation abates soon. 
In a large number of cases which I have observed the clinical history of 
this disease has been as mentioned above, except in one instance, when death 
occurred apparently from a sudden extension of the inflammation to the larynx 
and the occurrence of oedema glottidis. The diagnosis of follicular tonsillitis 
from diphtheria is easily made, except as regards the mildest form of diphtheria. 

Paltaceous Pharyngitis. — This form of pharyngitis usually occurs in low 
or debilitated states of the system. It occurs most frequently in the old 
and feeble and in such exhausting diseases as scarlatina and typhoid fever. 
As the term *• pultaceous " indicates, the inflammatory product is soft and 
friable, coming away in fragments when touched by the brush or sponge, 
without bleeding or any injury to the mucous membrane. Under the micro- 
scope it is found to consist of epithelial cells, often in fragments, nuclei and 
nucleoli, but no fibrin. When this substance is removed, as it readily can 
be, the mucous membrane underneath is entire, hyperaemic. and covered by 
a newly -formed epithelial layer. The appearance of the pultaceous product 
to the naked eye may closely resemble that in diphtheria, but its friable cha- 
racter, its epithelial nature, and the absence of fibrin which the microscope 
reveals render the diasfnosis certain. 



378 DIPHTHERIA. 

Scnrlatinous Pharyvgith. — The frequency of scarlet fever and diphtheria, 
and the facts that epidemics of the two are not uncommon at the same time, 
and that diphtheria often attacks a scarlatinous patient, render important 
the differentiation of scarlatinous pharyngitis from diphtheritic pharyngitis 
supervening upon and complicating the scarlatinous. Very commonly, when 
the pharyngitis of scarlet fever is severe, an abundant desquamation of 
epithelial cells occurs, which, aggregating, produce the pultaceous pseudo- 
membrane described above. This membrane resembles the diphtheritic in 
appearance, but its anatomical character, consisting as it does of epithelial 
cells as stated above, suffices to show that it is not a diphtheritic exudate. 
The grayish-white or brown product of scarlatinal inflammation seldom 
appears upon other parts than the tonsillar or lateral pharyngeal surfaces, 
whereas the diphtheritic membrane often appears upon the uvula, upon the 
posterior faucial surface, and in the nares, in addition to the tonsillar surface. 

Gangr€uo}f>^ Plianjngitu. — This variety of pharyngitis occurs oftener in 
connection with scarlet fever than with any other malady unless diphtheria, 
and when it complicates scarlet fever the appearance resembles very closely 
that in advanced cases of malignant diphtheria. The diagnosis is not dif- 
ficult if the case be observed from the beginning. The diphtheritic pseudo- 
membrane is in the commencement white or grayish-white. It presents the 
dark-gray color of gangrene only at an advanced stage by imbibition of 
blood and commencing disintegration. Gangrenous sore throat is from the 
first of a dark -gray, brownish, or even dark color. Gangrene produces a fetid 
breath ; malignant diphtheria does not produce fetor to such an extent until 
decomposition begins or gangrene supervenes. Gangrene not infrequently 
complicates the later stages of severe diphtheria. 

Herpetic Flmryngiiu No one can mistake herpes of the fauces in its 

commencement for diphtheria, the minute vesicles of the former disease are 
so unlike the diphtheritic exudate. But when the vesicles have disappeared 
and are replaced by minute ulcerations, covered by a white and adherent 
exudate, the differentiation of herpes from benign diphtheria is not easy. 
The presence of herpes labiaiis affords presumptive evidence that the pharyn- 
gitis is herpetic, but not conclusive, for it is sometimes also present in diph- 
theria. Immediately after the disappearance of the vesicles small rounded 
concretions distinct from one another occupy their place, presenting an 
appearance entirely unlike that of diphtheria, which exhibits at first a film, 
soon becoming a thick and firm patch. It is when the concretions unite, 
forming a patch, that the diagnosis is difficult. I need not state that herpetic 
pharyngitis, like follicular tonsillitis, is often mistaken for benign diphtheria, 
and vke versa. 

Ulcero-memhranovs Pharyngitis. — This is an extension of ulcero-mem- 
branous stomatitis. It is characterized by a necrosis, limited in extent and 
superficial, of the mucous membrane. The presence of ulcero-membranous 
stomatitis as the important part of the disease, predominating over the 
pharyngeal affection, aids to a correct diagnosis. Constitutional symptoms 
are slight or are wanting in this form of pharyngitis. Fever, albuminuria, 
and glandular swellings, which characterize diphtheritic pharyngitis, are 
absent or insignificant. The sphacelus over the tonsils, unlike that in diph- 
theria, is in patches isolated from one another. The microscope reveals 
epithelial cells and bands of elastic fibres pertaining to the chorion as the 
elements in the necrosed tissue. 

Anatomical Characters. — The characteristic and diagnostic feature of 
diphtheria is the formation upon one of the mucous surfaces, usually the 
fauces, or upon the skin denuded of its cuticle, of a whitish or grayish-white 
pseudo-membrane. This membrane, occurring upon mucous surfaces lined 



ANATOMICAL CHARACTERS. 379 

by pavement epithelium, penetrates and is incorporated with the mucous 
membrane, which undergoes necrosis. The mucous membrane when the 
pseudo-membrane is fully formed loses its vitality and becomes a part of 
the pseudo-membranous mass. It cannot, therefore, be detached without 
tearing the fibres of connective tissue and the vessels which unite the mucous 
membrane to the submucous tissues, until such time as it becomes detached 
by the sloughing process. Upon such mucous surfaces as are lined by 
columnar epithelium the pseudo-membrane does not form an integral con- 
nection with the mucous membrane, but lies over it or lines it, so that it can 
be removed without injuring it. This form of pseudo-membrane occurs 
upon the respiratory tract below the superior vocal cord. Above this cord 
squamous epithelium lines the larynx, except in front, where columnar 
epithelium occurs as high as the middle of the epiglottis. If croup occur 
during the course of diphtheria, and a pseudo-membrane form upon the 
laryngo-traeheal surface in addition to that already existing upon the faucial 
surface, the patient has both forms of pseudo-membrane described above. 
Moreover, in the vicinity of these pseudo-membranous inflammations, and 
extending from them, we ordinarily find a catarrhal inflammation of greater 
or less extent — an inflammation characterized by redness and swelling of the 
mucous surfaces and a muco-purulent secretion, but without the false mem- 
brane. Sometimes also, when diphtheria is occurring in a family, one of the 
children has a simple catarrhal inflammation of the fauces of a few days' 
continuance. If he have a pseudo-membrane upon any of the surfaces, it is 
not visible. These three forms of inflammation — that in which the mucous 
membrane undergoing necrosis becomes incorporated wdth, and forms an 
integral part of, the pseudo-membrane ; that in which the pseudo-membrane 
covers the mucous membrane, but is anatomically distinct from it; and that 
in which no pseudo-membrane occurs, the catarrhal — we are in the habit of 
designating by the term diphtheritic, inasmuch as they occur from the irri- 
tating action of the diphtheritic poison. Unfortunately, the most renowned 
living pathologist, A^irchow, restricts the use of the term diphtheritic to that 
form of inflammation in which mucous membrane undergoing necrosis forms 
part of the pseudo-membrane, while he does not apply the term diphtheritic, 
but the term croupous, to that form of inflammation, although occurring in 
a diphtheritic patient, in which the pseudo-membrane lies upon the mucous 
surface. This explanation seems to be necessary in order to avoid confusion 
in the use of the terms diphtheritic and croupous as employed by the school 
of Virchow. 

Soon after diphtheria commences, as manifested by fever and the concom- 
itant symptoms, we observe redness upon one of the surfaces which is to be 
the chief seat of the local manifestation of the disease. When the malady 
is contracted in the usual manner, this local manifestation is ordinarily upon 
the faucial surface and primarily upon the tonsillar portion. If there be a 
pre-existing inflammation of one of the other mucous surfaces, or a portion 
of the cuticle denuded of its epidermis and inflamed, the specific inflamma- 
tion is likely to appear primarily upon this part, as we have stated above, 
with or without its simultaneous appearance upon the faucial surface. 

The inflammation varies greatly in severity and extent. In a mild attack 
it is often limited to a part of the fauces, and there are few exceptions to the 
rule that the tonsillar portion is afl'ected, the redness gradually fading away 
in the healthy membrane be3^ond. But in the course of a few hours, in all 
except the mildest cases, the entire faucial surface presents the character- 
istic inflammatory redness and swelling and its follicles are tumefied and 
actively secreting. In severe cases the uvula is elongated and enlarged from 
infiltration, and the inflammation even extends to the submucous connective 



380 , DIPHTHERIA. 

tissue, which becomes hyperasmic and swollen, and the submucous lymphatic 
glands, especially the tonsils, also swell and are painful. The color of the 
inflamed surface is sometimes a deep bright red, almost like arterial blood ; 
in other cases it is a dusky red, which indicates, if there be no croupal symp- 
toms, an adynamic and dangerous type of the disease. The dusky-red hue is 
more common in secondary than in primary diphtheria. 

Within a day, and usually within a few hours, from the commencement 
of the inflammation a small, slightly-raised, whitish or grayish spot or patch 
is observed, usually upon the tonsillar portion of the inflamed surface — very 
significant as a diagnostic sign and as a forerunner of what is to happen. 
This patch, termed the pseudo-membrane, gradually becomes firmer, and at 
the same time thicker and broader from fresh exudations underneath. It 
retains for a time its grayish-white color, but it becomes brownish white from 
ao;e. In mild cases the pseudo-membrane is usually limited to the tonsillar 
surface, but in severe cases it covers the uvula, portions of the velum, the 
isthmus, and the walls of the pharynx, both lateral and posterior. It does 
not ordinarily attain a greater thickness than one-eighth to one-sixth of an 
inch. I have seen it, however, not far from one-third of an inch thick. 

Briefly stated, the pseudo-membrane of diphtheria is found to consist of 
fibrin, forming a delicate interlacing network, epithelial cells more or less 
altered by the inflammatory process, leucocytes, nuclei, mucus, and amor- 
phous matter. It also contains, as has been remarked above, diff'erent species 
of bacteria, of which the micrococci are most abundant. The significance 
of the bacteria is fully dwelt upon elsewhere in this article. The same 
pseudo-membrane is often firmer in one part than in another, the outer and 
central portions being more compact and tough for a time than that under- 
neath, which is more recent. After a few days, however, decomposition 
begins, and then that which was first formed becomes softer than the more 
recent production. When this occurs, the color of the exudation changes to 
a dirty brown, and its exposed surface is uneven and jagged from the partial 
separation of shreds and fibres. Sometimes the diphtheritic patch has a red-< 
dish tinge, due to rupture of the capillaries and escape of blood-corpuscles. 
Its lower or attached surface may be blood-stained, while the exposed surface 
has the usual grayish-white hue. 

The inflamed mucous membrane is not only hypersemic and infiltrated with 
serum, but it also contains numerous round white corpuscles (leucocytes), 
which may result in part from proliferation of connective-tissue corpuscles, but 
are believed by most pathologists, since Cohnheim's well-known discovery, to 
be in great part wandering white corpuscles of the blood which have escaped 
through the walls of the blood-vessels along with the fibrin. In the com- 
mencement of the diphtheritic inflammation, before the pseudo-membrane 
forms, we often observe a grayish tinge of the mucous surface, which is due 
to the crowding of the cellular elements in and underneath the mucous mem- 
brane ; for these newly-formed cells not only infiltrate the mucous membrane, 
but can also be traced into the submucous connective tissue. Even where 
the inflammation remains catarrhal, as it does over certain areas in all cases 
of diphtheria, this infiltration of the mucous and submucous tissues with 
cells is common. 

During the active period of diphtheria it is often astonishing to see -with 
what rapidity the pseudo-membrane returns when removed by force. A few 
hours sufiice to restore it as firm and extensive as before the interference. 
In the most favorable cases the membrane is detached in a few days, and 
is not reproduced. Its separation is promoted by the secretions underneath, 
especially by pus, which is secreted in abundance between it and the tissues 
underneath, which have preserved their integrity. In most instances it does 



AXATOJTICAL CHARACTERS. 381 

not separate in mass, but disappears by progressive liquefaction. Occasion- 
ally, even in cases which do not present a severe type, the diphtheritic 
patch does not disappear until the lapse of four or five or even six weeks, 
or if it softens and is detached another appears in its place. In these 
instances of an unusual prolongation diphtheria has been designated 
chronic. 

Such are the appearances, character, and history of the pseudo-membrane 
in this malady. Although its common seat is upon the fauces, and in mild 
cases it is limited to them, nevertheless all the mucous surfaces are liable to 
be attacked by the inflammation in consequence of infection of the blood, 
and therefore in severe cases, and even in cases of moderate severity, we often 
find the product elsewhere as well as upon the fauces, and in localities where 
from its mechanical effect it greatly increases the danger and even compro- 
mises life. The mucous membrane of the nostrils, mouth, lar3"nx, trachea, 
bronchial tubes. Eustachian tube, conjunctiva, oesophagus, stomach, intestines, 
vagina, prepuce, and even the delicate lining membrane of the middle ear, are 
at times the seat of diphtheritic inflammation with the characteristic product. 
In a case which occurred in the Nursery and Childs Hospital of New York 
the surface of the stomach was almost completely lined by the diphtheritic 
formation, so as apparently to abolish the function of this important organ. 
The occurrence, of the pseudo-membrane in the nares is common, and is 
attended by the discharge from the nose of thin mucus and pus. Nasal 
diphtheria involves great danger, from the fact that it is likely to give rise 
to systemic infection of a grave type. In the nursing infant it is also dan- 
gerous, since by its mechanical eff"ect it interferes with lactation. The thin, 
irritating discharge produces excoriations around the nostrils and upon the 
upper lip. I have met only one case of diphtheritic inflammation of the 
intestines in which the diagnosis was certain. A physician in whose family 
diphtheria was occurring became seriously sick with symptoms which closely 
resembled those of typhoid fever. After a ~ long sickness he expelled per 
rectum about one foot of pseudo-membrane of a cylindrical form, evidently 
derived from the surface of the intestines. In the subsequent months the 
patient suffered from constipation and severe abdominal pains, apparently due 
to contraction in healing of the large intestinal ulcer. Death finally occurred 
from this state of the intestines. The formation of the diphtheritic pellicle 
upon the vulva and vaginal walls is not infrequent, and in parturient women 
exposed to diphtheria it sometimes occurs upon the uterine walls, usually 
with a fatal result. A considerable number of cases are on record in which 
diphtheritic inflammation occurred upon the prepuce after circumcision, pro- 
ducing the usual pseudo-membrane, and in one instance in my practice, 
referred to above, it attacked the prepuce the day after I had dilated it with 
an instrument clean and free from infection. 

In mild cases of diphtheria, in which the pellicle is small, superficial, and 
limited to the fauces, systemic infection is usually slight : and it is the 
belief of many that the disease when of this mild type not infrequently 
remains local. But in grave cases, in which the diphtheritic pellicle is 
extensive and deeply imbedded, systemic infection commonly results, not- 
withstanding the efiicient local antiseptic treatment. The lymphatics and 
blood-vessels which are in immediate relation with the under surface of the 
pseudo-membrane take up poisonous ptomaines. Septic blood-poisoning is 
likely to occur in those cases in which the pseudo-membrane has become dark- 
gray and friable from decomposition, producing an ichorous discharge and 
offensive breath. 

The Blood. — The blood in cases of a severe tj^pe is usually darker than 
in health and the clots soft. After death from diphtheritic croup it is also 



382 DIPHTHERIA. 

dark from the excess of carbonic acid in it. The chemical changes which the 
blood undergoes in diphtheria are partially known. MM. Andral and Gavarret 
found a notable diminution of fibrin in grave infectious diseases, as typhoid 
fever, puerperal fever, etc., and it is not improbable that the same is true of 
diphtheritic blood, although the exudation of fibrin is so abundant. M. 
Bouchut and others have noted an excess' of the white corpuscles in the 
blood in diphtheritic patients, so that, instead of three or four in the field of 
the microscope, as many as sixty have been counted. M. Sanne writes of 
diphtheria : " It is necessary to recognize in the dark-brown blood an abnor- 
mal accumulation of the debris of the red corpuscles, debris of little abun- 
dance in the normal state, augmented considerably under the noxious 
influence of the diphtheritic poison, which has rapidly produced destruction 
of a great number of globules."^ Small extravasations of blood in the 
various organs are among the most constant lesions. They have been most 
frequently observed in the brain and its meninges, the lungs, spleen, and 
kidneys. In one case which I examined after death in the New York Found- 
ling Asylum the extravasations in and under the gastric mucous membrane 
produced mottling as great as that of the skin in measles. 

The most minute examinations of the organs in diphtheria yet published 
are those recently made by Oertel, and we will present a summary of them in 
the following pages. 

Brain and Spinal Cord. — The anatomical changes occurring in these organs 
are in a measure described in our remarks on diphtheritic paralysis. Oertel 
discovered, as the earliest anatomical change in the brain and spinal cord as 
well as in the membranes, a venous hypersemia, with small extravasations of 
blood, " not larger than a pea," in the white medullary matter of the brain, 
while in the cortical layer and in the central parts no extravasation was 
found. In the most severe forms of the disease small hemorrhages not 
larger than a pea were found not only in the cerebral meninges, but also 
in various parts of the brain. These produced some softening in their imme- 
diate neighborhood. These small hemorrhages have been found also in or 
upon the medulla oblongata and spinal cord, but with less softening. Buhl, 
in addition to the extravasations in and upon the brain and spinal cord, dis- 
covered in one case great enlargement of the anterior and posterior roots and 
the ganglionary swellings of the spinal nerves. The swelling was found to 
be due to the accumulation of cells and nuclei in the sheaths of the nerves 
and to extravasations of blood. These anatomical changes were most marked 
at the roots of the lumbar nerves. (For further particulars relating to the 
pathology of the nervous system in diphtheria the reader is referred to our 
remarks on Paralysis.) 

Tonsih. — Covering these organs is the pseudo-membrane, consisting of 
the usual fibrillar meshwork, enclosing leucocytes, changed epithelial cells, 
and amorphous matter : the older the exudation the coarser is the network. 
The adenoid tissue and the septa have undergone hyperplasia. The follicles 
are crowded with cells which have undergone necrobiosis. As a result of the 
necrobiosis masses are formed of various shapes and sizes, staining deeply. 
In consequence of the necrobiosis and degenerative changes the follicles 
become a hyaline network infiltrated with leucocytes and granules. In 
advanced cases the adenoid and connective tissues undergo a similar necro- 
biotic change, and are so blended with the pseudo-membrane that it is diffi- 
cult to determine where the latter ends and the tonsillar tissue begins. The 
vessels of the tonsils undergo a hyaline thickening of their walls, and if this 
occur chiefly in the intima total occlusion may result. In the tissues imme- 
diately surrounding the tonsils hyaline degeneration of the muscular fibres 

^ Traite de la Diphtherie, p. 107, Paris, 1877. 



ANATOMICAL CHARACTERS. 383 

occurs (Zenker's degeneration), and the connective tissue between the nius-' 
cuk\r fibres is infiltrated with leucocytes. 

Fancied Surface and Uvula. — These parts are often also covered with 
pseudo-membrane, and are more or less changed by the application of reme- 
dies. The line of separation of the exudate and underlying tissues cannot 
be readily distinguished. The upper portion of the diphtheritic pellicle if 
filled with bacteria and with leucocytes and other cells which have under 
gone necrobiosis. In the mucosa next to the pseudo-membrane hyaline 
degeneration of the connective tissue occurs, and the mucosa is infiltrate) 
with cells which have undergone marked changes. The nuclei of the con 
nective-tissue cells exhibit various stages of degeneration and decay, thougl 
the cells may retain their form. The deeper layers of the mucosa, like the 
upper, are infiltrated with leucocytes. 

The uvula in severe cases is usually swollen and cedematous, and some- 
times entirely covered by the diphtheritic pellicle. When the uvula is 
involved in the general faucial inflammation, necrobiosis of the cells and 
nuclei occurs in every part of it. The cells in the arterial adventitia and 
in the perivascular tissue exhibit necrobiotic change, their nuclei being dis- 
integrated. In the uvula, also, hyaline degeneration occurs in the walls of 
the vessels. 

Epiglottis. — The epithelial cells covering the epiglottis undergo marked 
proliferation early in the disease, and are infiltrated with leucocytes. They 
soon begin to undergo degeneration, forming granular masses. Areas of 
necrobiosis occur, and finally hyaline degeneration of the network takes place. 
The leucocytes extend deeply into the mucous membrane, followed by degen- 
erative and necrobiotic changes. In places the epithelium is thrown ofi", and 
a pseudo-membrane forms of exuded fibrin and necrobiotic leucocytes and 
epithelium. Bacteria, along with leucocytes and degenerated epithelial cells, 
occupy the meshes of tiie pseudo-membrane. 

Lungs. — The anatomical characters of the a^ir-passages are fully treated of 
in the article on Diphtheritic Croup. Catarrhal bronchitis is common in diph- 
theria. It is not often absent in croup, and one of the chief sources of danger 
in this disease is the extension of pseudo-membrane from the laryngo-tracheal 
surface to the bronchial, and the transformation of the catarrhal into a croup- 
ous inflammation. When bronchitis occurs the inflammation creeps down- 
ward gradually from the laryngo-tracheal surface, and its severity is propor- 
tionate to the degree of extension. AVhen there is a general bronchitis and 
it is very liable to become croupous, the muco-purulent exudation is abun- 
dant. When pseudo-membranous bronchitis occurs, there are usually portions 
of the bronchial tree in which the inflammation remains catarrhal. One of 
the chief sources of danger in diphtheritic croup is the extension of the 
inflammation to the bronchial tubes and the abundant secretion of muco-pus, 
which clogs the tubes and prevents proper decarbonization of the blood. 
When the bronchitis becomes croupous, a thin, easily-detached film appears 
upon the intensely-red, hypersemic, and swollen bronchial surface. It increases 
in thickness and firmness and assumes a dull white color. Still later it becomes 
thicker, firmer, and of a brownish-gray color. Whatever the stage of the 
inflammation, the pseudo-membrane can always be readily detached from the 
bronchial surface, since its relation to it is one of apposition, and not of inte- 
gral connection, as upon the pharyngeal surface. In the large tubes and 
those of medium size hollow cylinders, more or less complete, form ; but in 
the smaller tubes, if the pseudo-membrane extend to them, solid cylinders 
are produced. Frequently, in the bronchial croup of diphtheria, while the 
entire bronchial surface is intensely red and swollen, the pseudo-membrane is 
absent in certain parts ; in other parts it forms cylinders, in other parts still 



384 DIPHTHERIA. 

longitudinal bands of a ribbon shape are produced, and in more or fewer of 
the minuter tubes plugs which entirely fill the lumina and prevent the entrance 
of air. The alveoli beyond these plugs gradually collapse, and more or fewer 
of them return to the unexpanded foetal state. From the tubes which are 
still pervious the muco-pus is with difficulty expectorated on account of its 
viscidity, and this thick secretion contains floating particles of pseudo-mem- 
brane. Pseudo-membranous bronchitis in diphtheria is in nearly all instances 
an extension of a laryngo-tracheal croup. It occurs, according to Sanne, most 
frequently between the second and sixth days. 

Various forms of pulmonary disease occur in diphtheria, usually as a 
complication and often as a final result of the downward extension of inflam- 
mation from the larynx, trachea, and bronchial tubes, Splenization, atelec- 
tasis, and broncho-pneumonia are common complications of diphtheritic croup. 
Broncho-pneumonia, like pseudo-membranous laryngo-tracheitis and pseudo- 
membranous bronchitis, upon which it largely depends, occurs usually in the 
first week of diphtheria. In 121 cases of broncho-pneumonia complicating 
diphtheria, observed by Sanne, the pneumonia commenced in 2 on the first 
day of diphtheria and in 71 between the second and sixth days inclusive. 

Pulmonary congestion, occupying by preference the depending portions 
of the lungs, especially the posterior and inferior portions of the lower lobes, 
is also not infrequent. It occurs when respiration is obstructed in croup and 
when the circulation is feeble in consequence of heart-failure. In the dyspnoea 
which accompanies paralysis of the pneumogastrics venous congestion of the 
lungs commonly occurs. 

Peter found the lesions of pleurisy 9 times in 121 autopsies in diphtheria, 
and Sanne observed them in 20 cases. The latter writer says : " All forms 
of diphtheria, but particularly croup and pseudo-membranous bronchitis, 
are to be found with pleurisy. Pleurisy always accompanies some other 
phlegmasia." 

Vesicular emphysema commonly occurs during the progress of croup. 
Whenever, in consequence of occlusion of the tubes, a considerable part of 
a lung fails to receive air, its alveoli begin to retract and collapse, and the 
alveoli which receive air, which are principally those in the superior and 
anterior portions of the lung, are over-distended, since their function is com- 
pensatory. Vesicular emphysema consequently results, and in exceptional 
instances the vesicles rupture and the escaped air passes into the connective 
tissue, producing interstitial emphysema. 

Pulmonary apoplejcy occasionally occurs, the extravasations usually being 
of small size and disseminated through the lungs. It is most frequent in 
malignant cases — in cases attended by profound blood-poisoning. It has been 
attributed in some instances to pulmonary emboli resulting from cardiac 
thrombosis, or microbic masses intercepted in the capillaries. Pulmonary 
oedema, also occasionally occurs, especially in cases of bronchial croup, pul- 
monary congestion, and broncho-pneumonia. Oertel in his recent microscopic 
examinations of the lungs noted subpleural hemorrhages and hemorrhages 
extending to the alveoli, which were compressed. " Leucocytes infiltrated 
the alveolar septa, and in later stages invaded the alveoli, the epithelium of 
which became detached, and the characters of catarrhal pneumonia were thus 
produced. Some alveoli contained fibrinous exudation, and in one severe case 
the alveolar contents consisted of nuclei which exhibited disintegrating 
changes somewhat like those in necrobiosis." 

Lymphatic Glands. — Enlargement of the cervical and submaxillary glands 
is of common occurrence in diphtheria, and it is a diagnostic symptom of some 
value. Hyperplasia of the cells of these glands occurs, with numerous 
hemorrhagic points in their capsules and in the periglandular tissue. Points 



ANATOMICAL CHARACTEES. 385 

of necrobiosis, staining faintly, occur in the glands, more in the cortical than 
in the central portions. The cells exhibit evidences of disintegration, and 
when this process is advanced granular masses form in the affected foci. 
Hyaline degeneration is also observed in portions of the glandular tissue, a 
degeneration common in other organs in diphtheria. Where disintegration 
is not too far advanced cells with polymorphous nuclei are observed — evidence 
of an active hyperplasia. Hyperplasia with points of hemorrhagic extrava- 
sation takes place also in the bronchial glands, but fewer points of necrobiosis 
occur than in the cervical and submaxillary glands, and these chiefly in the 
follicles. The lymph-ducts may contain no normal cells, and only those which 
have disintegrated nuclei along with other products of disintegration. 

Heart. — The state of the heart will be in part described in our remarks 
relating to cardiac paralysis. Small extravasations of blood under the peri- 
cardial, and less frequently the endocardial, surface have been observed. 
Oertel attributes these hemorrhages to changes in the walls of the vessels 
caused by the diphtheritic virus, and Buhl, to nuclear proliferation in the 
walls and mechanical obstruction. Leucocytes in masses often occur under 
the pericardium and endocardium and between the muscular fibres. Some- 
times the muscle-nuclei have undergone segmentation and degenerative 
changes. These nuclear changes occur mostly in fibres under the endo- 
cardium and around the coronary arteries. The nuclei in the muscular coat 
of the arteries are increased in size, and slight proliferation and desquamation 
of the endothelia and infiltration of the adventitia also take place. 

Mouthy Stomach, Intestines. — The diphtheritic pellicle sometimes forms in 
the cavity of the mouth, generally in small patches ; but the buccal surface 
is usually only superficially involved, except upon the tongue, where the 
pellicle extends more deeply. I have elsewhere stated that the diphtheritic 
exudate sometimes occurs upon the surface of the stomach and portions of 
the intestines, producing more or less destruction of the mucous membrane. 
Necrobiotic foci have been observed by Bizzozero and Oertel in the intestinal 
follicles and agminate glands, but to a less extent than upon the respiratory 
surfaces. xlctive cell-proliferation and disintegration and cleavage of nuclei 
occur, but these altered cells are mixed with others which are normal. The 
epithelium is for the most part retained and normal, and hyaline changes 
have not been observed in the gastro-intestinal vessels. The mesenteric 
glands sometimes undergo enlargement from hyperplasia, especially when 
the intestines are affected and points of necrobiosis occur in them. For the 
most part, however, the gastro-intestinal surface is less frequently affected 
than other mucous surfaces. 

Spleen. — The diphtheritic virus reaches this organ through the blood- 
current. The spleen is swollen, so as to render its capsule tense. The pulp 
is soft, rising up through the cut surface of the capsule ; the follicles are 
large and prominent ; in the pulp are extravasations of blood and hasmatoidin 
masses, and the vessels are distended. Hyperplasia of the splenic corpuscles 
occurs, which is most marked around the bifurcations of the arteries, so that 
the reticulum is less prominent. The follicles are surrounded by a wide zone 
of the reticulated cells, among which we find lymphatic corpuscles, leucocytes, 
and large round cells. The nuclei in the cells undergo two changes : first, 
direct segmentation as in ordinary cell-division, and fragmentation, in which 
the chromatin is broken up in small, irregularly-disposed masses and the 
nuclear juice is susceptible of staining. In the Malpighian follicles either 
numerous epithelioid cells form, as mentioned by Stilling,' or large cells occur. 
The latter stain better by coloring reagents than the epithelioid cells, but less 
than the leucocytes. The epithelioid cells occur mostly in young patients. 

^ Virchoiv's Archiv, Bd. ciii. 
25 



386 DIPHTHERIA. 

A wide zone of leucocytes surrounds and invades the follicles. The necro- 
biotic process also occurs as in other organs, beginning with nuclear disinte- 
gration, and when at its maximum the follicles are surrounded and loaded with 
the altered nuclei furnished by the round or epithelioid cells. Hemorrhages 
also occur in the follicles. In some protracted cases the vessels of the pulp 
exhibit the hyaline degeneration. 

Liver. — Capillary hemorrhages take place within the capsule, and occa- 
sionally within the parenchyma. Leucocytes occur at certain points within 
the liver, infiltrating the tissue of the organ. They occupy the interlobular 
spaces and do not exhibit nuclear changes. The hepatic cells are unchanged 
or they become fatty. 

Kidneys. — Albuminuria occurs from different causes, as we have stated 
elsewhere. Feeble heart-action, obstructed respiration, fever, and the direct 
irritating action of the diphtheritic virus upon the blood and the kidneys, 
are sufficient causes. The kidneys may be normal in cases of albuminuria, 
or exhibit different degrees of parenchymatous inflammation. Hemorrhages, 
glomerulitis, and disseminated nephritis are common lesions observed in the 
kidneys in those who have died having diphtheritic albuminuria. Hemor- 
rhagic points occur not only under the capsule, but also in the glomeruli and 
in and between the tubules. Cell-infiltration takes place around the vessels 
and the cells exhibit nuclear disintegration. On examining the glomeruli, 
thickening of Bowman's capsule is sometimes observed, with some albuminous 
exudation underneath it, and epithelial proliferation and desquamation. The 
nuclei and endothelia of the glomerular capillaries are increased, and the 
chromatin and nuclear juice have undergone disintegrating and degenerative 
changes — results of inflammation. The capillaries are therefore in a degree 
diseased through the action of the blood-poison. The epithelium of the 
convoluted and straight tubes is also diseased. The epithelial cells, under- 
going cloudy swelling, become detached from the basement membrane, fill 
the lumina with the necrosed product, and some of them escape, forming 
casts in the urine. Occasionally only the outer portion of the cell is necrosed 
and detached, the part adjacent to the basement membrane containing the 
nucleus remaining in situ. Oertel says that when the entire cells are thrown 
off granular casts are formed, but if only the outer portions are lost hyaline 
casts are produced. The collecting tubes, filled with granular masses con- 
taining broken nuclei, cells, and epithelia, may be dilated. 

The above description of the anatomical changes which occur in the 
various organs is for the most part a resume of the recent investigations by 
Oertel. Whether his published statement will be fully sustained by subse- 
quent microscopic examinations remains to be seen. 

Symptoms. — Diphtheria, like scarlet fever, varies greatly in severity, 
from a form so mild that medical advice is not sought and the child is not 
even confined to his home, to a form so severe that the S3"stem is at once 
overpowered and the patient is in a critical state from the first. In general 
in the commencement of an epidemic the symptoms are more severe than 
when the epidemic influence is abating. During the continuance of the 
attack the prominent symptoms, such as arrest attention, are often dispro- 
portionate to the gravity of the attack. Striking cases illustrative of this 
fact have occurred in my practice, the friends not supposing that there was 
any serious ailment, and not seeking medical advice until the fatal termina- 
tion was near. 

In henign diphtheria the initial symptoms are often slight, such as 
languor or lassitude, slight chilliness succeeded by fever of a light form, 
mild headache, pain or aching in the body or limbs, thirst, and impaired 
appetite. Usually some soreness of the throat is noticed in swallowing soon 



SY3IPT0MS. 387 

after the attack begins, and this continues. But the patient with mild diph- 
theria often continues to walk about, in the belief that he is affected with a 
slight and temporary ailment. Children with mild diphtheria in the poorer 
families are usually allowed to go abroad, and do great harm by propagating 
the disease. The symptoms in these mild cases so closely resemble those 
from a severe cold that the disease is liable to be mistaken for it. The slight 
tenderness or sensation of fulness in the fauces usually experienced by those 
old enough to express their sensations should always lead to an examination 
of the fauces, when the character of the attack will frequently be apparent. 
A distinguished clergyman of the Pacific coast who fell a victim to this dis- 
ease dreamed a few nights before he complained of his illness that his throat 
was cut. Doubtless the diphtheritic inflammation had already commenced, 
so that what seemed a "forewarning had a natural explanation. So insidious 
was the commencement in this case that the disease had advanced beyond all 
hope of relief when medical advice was first sought. 

Soon after the attack commences inspection of the fauces reveals redness 
of the tonsillar surface, and this extends until the entire fauces present an 
injected appearance. After the lapse of twelve to thirty-six hours, or even 
as late as forty-eight hours, from the commencement of the disease, the 
diphtheritic exudate begins to form over the tonsils, producing the character- 
istic pellicle. Before it forms we often observe a grayish color of the prom- 
inent part of the tonsils, produced by the infiltration of the mucous mem- 
brane, and even of the surface of the tonsils, with newly-formed cells. The 
exudate may appear as points, which coalesce, forming a patch, or as a pellicle, 
which soon becomes thicker and at the same time firm. Its anatomical cha- 
racters are described elsewhere. 

But in most cases, in all except of the mildest type, the initial symptoms 
are more severe than we have delineated above. The attack in the ordhiary 
as well as severe form of diphtheria commences abruptly, like scarlet fever, 
without a premonitory stage and with pronounced symptoms from the first. 
The temperature rises to 102°, 103°, or even 10-4° F,, with corresponding heat 
of surface, thirst, languor, loss or impairment of appetite, tenderness of 
throat, etc. Delirium as well as eclampsia may occur ; but both are rare. 
The temperature ordinarily begins to fall after the second or third day in 
favorable cases, and often in those of a grave and fatal type. Subsequently 
to the third or fourth day the temperature is frequently but little elevated. 
The diphtheritic poison, when the system is fully under its influence, does 
not exhibit any marked tendency, like that of scarlet fever, to increase the 
animal heat. Even in profound and fatal diphtheritic blood-poisoning rap- 
idly approaching an unfavorable termination the thermometer often indicates 
nearly the normal temperature, so that the inexperienced practitioner may be 
deceived by this fact in his prognosis. A continued elevation of temperature 
considerably above the normal should lead the physician to examine for some 
complication, perhaps nephritis. 

The tongue is moist and slightly furred. Many patients vomit in the 
commencement ; and if this symptom cease or be not repeated it is not of 
grave import ; but vomiting occurring often, so that a considerable part of 
the food is rejected, is common in grave cases and is an unfavorable prog- 
nostic symptom. It frequently is due to uraemia. The appetite in severe 
cases is usually poor. Repugnance to food from loss of appetite and pain 
in swallowing characterize severe forms of the disease. There are no notable 
symptoms referable to the state of the intestines. The stools appear normal, 
except as they are changed by the medicines prescribed. In all cases except 
the mildest a rapid destruction of red corpuscles occurs and a relative increase 
of white corpuscles. Hence the anaemia, which is soon manifested by pallor 



388 DIPHTHERIA. 

of the surface, and which rapidly increases as the disease advances. The 
early loss of the tendon reflex has recently been brought to the notice of the 
profession. It often occurs as early as the first, second, or third day. It is 
fully treated of in our remarks relating to diphtheritic paralysis in subsequent 
pages. It is a symptom of diagnostic value. Diphtheritic inflammations 
have a marked tendency to produce hyperplasia, and consequent notable 
enlargement of the lymphatic glands in their immediate neighborhood. The 
poisonous and irritating products of the inflammation upon the surface taken 
up by the lymphatics and deposited in the adjacent glands produce in them 
tenderness, swelling, an increased afflux of arterial blood, and a rapid increase 
of the cellular elements. An inflammation both of the lymphatic ducts and 
glands arises, with more or less oedema and sometimes inflammation of the 
adjacent connective tissue. Suppuration of the glands and connective tissue, 
though it may occur, is much less frequent than in scarlet fever. 

Temper at LIT a. — There is probably no other disease in which the thermom- 
eter furnishes so little aid to an understanding of the case as in this, since 
the degree of fever does not sustain any fixed relation to the amount of 
blood-poisoning. Malignant diphtheria with profound blood-poisoning and 
approaching a fatal termination may be almost apyretic, while a benign form 
of the disease with but little blood-poisoning may commence with consider- 
able fever (102°, 103°, or 104° F.). Fever in diphtheria is rather a symp- 
tom of the inflammation than of the blood-poisoning. Considerable elevation 
of temperature in diphtheria usually indicates an active pharyngitis, ton- 
sillitis, laryngo-tracheitis, bronchitis, pneumonia, or nephritis. Therefore, 
although the thermometer does not aid in determining the amount of blood- 
poisoning, it enables us to form an opinion in regard to the extent and 
severity of the inflammation which may be present. The thermometer is 
also useful when diphtheria occurs as a complication of another constitutional 
disease, as scarlet fever, measles, typhoid fever, since it indicates the severity 
of this disease. 

Such is the clinical history of diphtheria as it usually occurs, its local 
manifestation being primarily upon the tonsillar portion of the fauces, and 
extending from the tonsils, when the case is severe, to the posterior surface 
of the fauces, over the anterior and posterior pillars, and to the uvula. The 
uvula, when it is involved, becomes greatly swollen, even two or three times 
its normal size, so as to lie upon the tongue, and, especially if it be covered 
by a pseudo-membrane, to fill up the space between the swollen tonsils and 
intercept the view of the posterior fauces. When the inflammation is intense 
and the pseudo-membrane has not yet formed or has been removed by solv- 
ent applications, the tonsillar portion of the fauces often presents a grayish 
appearance from infiltration of leucocytes. This infiltration, if so great as 
to obstruct the circulation, leads to necrosis ; but, as we have stated else- 
where, the necrosis of the mucous membrane is more likely to occur when 
it is still covered by the pseudo-membrane, the pseudo-membrane and mucous 
surface being incorporated with each other and being detached together. The 
color of the pseudo-membrane, at first whitish or a grayish white, becomes. 
in a few days, in severe cases, a yellowish brown by the action of the atmo- 
sphere and sometimes by extravasation of blood. If the membrane be abun- 
dant, it is likely to have in a few days a musty and ofl"ensive odor, due to com- 
mencing decomposition. The constant inhalation of the highly poisonous gases 
which result is detrimental to the patient, and they increase the danger of 
infection in others. However, with the use of disinfectants, now so com- 
monly employed, the poisonous gaseous products of decomposition are not so 
common as in former times. Since the pseudo-membrane is incorporated 
with the mucous membrane and capillaries penetrate its under surface, forci- 



SYMPTOMS. 389 

ble detachment of the pellicle is likely to give rise to hemorrhage. Hemor- 
rhage is always a l3ad prognostic sign. The duration of the pseudo-membrane 
is very variable. On the average in favorable cases it is from one to two 
weeks. There are cases, however, in which the ulcerated surface is long in 
healing, and the ulcers are covered many days with the grayish-white diph- 
theritic exudate. In exceptional cases, at the close of the third or even 
fourth week we occasionally observe on the faucial surface diphtheritic 
patches two or three lines in diameter, without surrounding inflammation, 
in those who consider themselves nearly well and who would appear in the 
streets if they were allowed to do so. \\e will consider elsewhere how long 
enforced seclusion of the patient should be enjoined in order to prevent the 
propagation of the disease to others. 

Xares. — Usually inflammation of the nostrils occurring in diphtheria is 
secondary to that of the pharynx. The pharyngitis has continued one or 
more days when a discharge of a thin serous appearance occurs from the 
nostrils. This is attended by swelling of the Schneiderian membrane ; and in 
proportion to the amount of swelling the respiration through the nostrils is 
embarrassed. As the inflammation continues the swelling increases and res- 
piration is accompanied by a nasal snuffle, or the occlusion of the nostrils is 
so great that it is performed entirely through the mouth. The impediment 
to respiration in infants at the breast, so as to necessitate spoon-feeding, we 
have alluded to above. The discharge is very acrid and irritating, causing 
excoriation around the entrance of the nostrils and even upon the cheeks. It 
soon becomes more viscid or less fluid than at first, and it presents a creamy 
appearance from the large proportion of pus-corpuscles. When the inflam- 
mation of the nares is severe, the glands around the articulation of the lower 
jaw usually undergo hyperplasia, becoming nodular and prominent, so as to 
be apparent not only to the touch, but also to the sight. 

Although, commonly, diphtheritic inflammation of the nasal surface is 
secondary to that of the fauces, it is sometimes the primary inflammation. 
It may exist for some days before the fauces become aflfected, and under 
such circumstances the diagnosis is frequently not made until the disease is 
in an advanced stage and profound blood-poisoning has occurred. In nasal 
diphtheria the pseudo-membrane probably occurs as early as in other forms 
of diphtheritic inflammation, but being usually out of sight it is not observed 
in the first days or until it has extended so that its anterior edge can be seen 
on inspecting the nasal fossa. From its concealed position it is easy to per- 
ceive why the disease is so frequently overlooked, and a simple nasal catarrh 
is supposed to be present when there is no inflammation of the fauces to aid 
the diagnosis or it is late in appearing. 

Nasal diphtheria always involves great danger, since it is very liable to 
give rise to systemic infection from the large number of lymphatics lodged 
in the connective tissue of the nares. In certain severe cases accompanied 
by swelling of the face there is reason to think that the inflammation has 
entered the antrum of Highmore — a very serious extension. It sometimes 
extends up the tear-duct, producing its occlusion, and also along the Eusta- 
chian tube. Hemorrhage sometimes occurs in nasal diphtheria. In those 
who recover the Schneiderian membrane returns slowly to its normal state. 

The Eye. — We have stated above that the inflammation sometimes passes 
along the tear-duct to the conjunctiva, but in other instances the inflamma- 
tion occurs independently of this mode of propagation. Thus, if a child 
with simple conjunctivitis contract diphtheria, the pre-existing inflammation 
is very liable to assume a diphtheritic character, in accordance with the 
law already stated, that diphtheria attacks by preference surfaces that are 
already inflamed. I have elsewhere stated that diphtheria at one time entered 



390 DIPHTHERIA. 

the ophthalmic wards of the New York Foundling Asylum, and three chil- 
dren, under treatment for granular lids, who contracted the disease, had 
diphtheritic inflammation of the lids, with the usual pseudo-membranous 
exudate. The result of diphtheritic conjunctivitis, even with prompt and 
appropriate treatment, is likely to be disastrous as regards the eye. The 
eyelids become red and greatly swollen from oedema, and their under sur- 
face is soon lined by a thick and firm pseudo-membrane. The eye itself is 
the seat of chemosis. The pseudo-membrane upon the ocular conjunctiva is 
less firm, not so thick, and more in flakes than that upon the palpebral con- 
junctiva. The eye aff"ected by this disease should be closely watched and 
promptly and efficiently treated ; but, unfortunately, under the most judi- 
cious treatment the cornea is likely to become hazy and sloughing or ulce- 
ration follow, with total destruction of sight and perhaps prolapse of the iris. 

The Ear. — The ear may become inflamed by extension of the inflamma- 
tion along the Eustachian tube from the fauces. The opening of this tube 
upon the faucial surface is small and slit-like in the child, and moderate inflam- 
mation and exudation are sufficient to close it. When this occurs the patient 
complains of pain in the site of the tube and in the ear. The formation of a 
membrane plugging the tube and the extension of the inflammation to the, 
ear, producing an otitis media, add very much to the gravity of the case. 
Perforation of the drum, caries of the bones of the ear, and that grave dis- 
ease otitis interna may occur, increasing very much the gravity of the case. 
Fortunately, this extension of the inflammation is not frequent. It does not 
often occur except in those malignant cases which are likely to be fatal from 
other causes. Sometimes, also, a diphtheritic otitis externa occurs. It is 
usually preceded by a catarrhal inflammation which has arisen from other 
causes and was present when the diphtheria commenced. Bezold described 
three cases of otitis externa with a diphtheritic pellicle upon the drum.' 
Moos and Cailan have also narrated cases. 

The Mouth. — During the progress of diphtheria any sore or abrasion of 
the mouth is likely to become the seat of the diphtheritic exudate. Usually 
the fauces, and sometimes the nares, are at the same time aff'ected. The 
diphtheritic pellicle, commonly of small extent, may appear upon the inside 
of the cheek, the tongue, gums, and lips. Usually the inflammation of these 
parts is of secondary importance, but in malignant or highly septic cases it 
may be attended by considerable infiltration and thickening. Buccal diph- 
theria, if severe, is painful, and it may interfere with the proper nutrition. 
The clinical history of diphtheritic inflammation of the fauces and respira- 
tory tract below the epiglottis is sufficiently presented elsewhere. 

(Esojyhagus, Stomach, Intestines. — The upper part of the oesophagus not 
infrequently participates in the inflammation of the pharynx. Its walls are 
thickened, and the pseudo-membrane presents the same characters as upon 
the fauces. Occasionally, nearly the entire oesophagus is the seat of diph- 
theritic inflammation, the oesophageal walls being greatly thickened from 
infiltration of cells and very vascular. In one of the cases, related in a 
foregoing page, of diphtheria of the newly-born, the oesophagus was in 
nearly its entire length covered by the diphtheritic pseudo-membrane. In 
only one instance have I observed a severe diphtheritic gastritis. In this 
case nearly the entire surface of the stomach was covered by a thick pellicle. 
Probably the inflamed follicles did not secrete normal pepsin. A few cases 
are on record of diphtheritic inflammation of the intestines. Dr. A. Jacobi 
relates the case of a child of three years who had diphtheritic enteritis. 
Fever, moderate tenderness of the abdomen with but little tympanitis, con- 
stipation, and great prostration, were the prominent symptoms. The autopsy 

^ Virchoiv's Archiv, Ixx. 329. 



SY3IPT0MS. 391 

revealed the presence of a diphtheritic inflammation in the jejunum and ileum, 
the membrane consisting of '' a dense network with granular contents." The 
most marked case of diphtheritic intestinal inflammation which has come 
under my notice was that of a physician to whose case I have elsewhere 
referred. He lost his appetite, had fever, lost flesh and strength, had distress 
in the abdomen which raised the suspicion of a typhoid fever ; but at the 
usual time for the termination of a self-Jimited fever no abatement of symp- 
toms occurred. Finally, after weeks of suff'ering, he expelled a cast of the 
intestine several inches in length, probably from the colon. Obstinate con- 
stipation was the most prominent symptom during this time and subsequently, 
due probably to cicatrization and contraction of the intestine. The patient 
died from the effects of the disease several months subsequently, having suf- 
fered constantly from faulty digestion, abdominal pain,* and constipation, which 
no treatment could relieve or benefit. 

Genlto- Urinary Organs. — Diphtheria of the prepuce commonly occurs after 
some injury. It either arises by direct inoculation upon an abrasion or wound, 
or is contracted by exposure to an infected atmosphere. Many cases are on 
record. I have elsewhere stated that the eminent surgeon M. Germain See, 
whose practice is in a locality where diphtheria is endemic and very prevalent, 
now recommends stretching of the prepuce in nearly all cases of narrow and 
adherent prepuce, rather than circumcision, for the reason, among others, that 
diphtheria is more liable to follow the latter operation. Diphtheria of the 
prepuce is contracted by the use of infected instruments, sponges, or fingers 
in the operation of circumcision, or by the performance of the operation with 
clean instruments and hands, but in an infected atmosphere. Thus, Dr. F. 
Lange saw a case of preputial and scrotal diphtheria in a child of three weeks 
who had been circumcised when diphtheria was occurring in the family.-^ Dr. 
Grreves states that a boy who had been circumcised for phimosis was admitted 
into the Liverpool Infirmary with an unhealthy prepuce which had never 
healed after the operation. Weak and angemic when admitted, he continued 
to sink, and died of heart-failure. The wound and subjacent tissues were 
infiltrated with micrococci presenting the same characters as those in pharyn- 
geal pseudo-membranes. In a preceding page I have alluded to a case, 
related by Mr. Phillips, of preputial diphtheria occurring after circumcision 
by infected instruments, and have related a case in my own practice of a 
severe diphtheria of the prepuce, and simultaneously of the fauces, occurring 
after instrumental dilatation of the foreskin. Dr. A. Jacobi states that he 
incised the upper part of the prepuce in a healthy boy of three years, 
employed stitches, and applied carbolized dressing. On the following day 
diphtheria attacked the wound, with the usual swelling and erysipelatous 
appearance. The stitches were removed, but death occurred four days after 
the operation. Dr. A. Jacobi also relates the case of a boy of four years 
whom he circumcised, and dressed the wound with antiseptic solutions. 
Diphtheria supervened, and in a few days the entire prepuce and a small 
portion of the penis' became gangrenous. The boy eventually ■ recovered, 
with deformity of the organ. 

Billroth has called attention to the fact that diphtheria in localities 
where it is prevailing is likely to attack wounds produced by operations on 
the urinary apparatus, as after lithotomy or urethrotomy, and in cases of 
ectopia vesicae and vesico-vaginal fistula. The inflammation under such cir- 
cumstances is usually localized, but it may extend to the retro-peritoneal 
connective tissue and produce a fatal peritonitis. The marked liability of 
the uterus, vagina, and vulva when wounded in any way, as in parturition, 
to become the seat of diphtheritic inflammation in case of exposure to the 
1 Medical Record, July 10, 1880. 



392 DIPHTHERIA. 

infection, is well known to the profession, and no prudent obstetrician will 
attend an obstetrical case after visiting a diphtheritic patient without change 
of apparel and personal disinfection. Some years ago I was summoned to a 
young lady who during the week following her confinement insisted on 
seeing her child, then in the commencement of diphtheria. The child was 
brought to her bedside for a moment. Within a day or two she was 
attacked with a violent form of metro-peritonitis, which was speedily fatal. 
In children diphtheritic vulvitis and vaginitis occasionally occur, associated 
or not with pharyngitis. I. Zit has records of thirteen cases of diphtheritic 
vulvitis, in some of which inflammation was the first manifestation of diph- 
theria. Diphtheritic inflammation of the vulva and vagina is believed to be 
rare without a pre-existing catarrhal inflammation. 

Skin — An efflorescence is sometimes observed upon the skin during the 
time in which the temperature is exalted. It is the erythema fiigax of der- 
matologists suddenly appearing and disappearing. This eruption, which is 
common in febrile and inflammatory aff"ections of childhood, does not seem 
to present any peculiar characters in diphtheria. But there is another erup- 
tion which I have not infrequently observed, and which is attributable to 
diphtheritic toxaemia or septicaemia. It appears after the sixth or seventh 
day in the form of red points or spots not more than a line in diameter, and 
interspersed with patches of efflorescence with irregular margins, one to two 
inches in diameter. This roseolar eruption is slightly raised, like that of 
measles. Sometimes it is punctate. It disappears on pressure, and in m}^ 
practice it has usually appeared in grave cases in which there were other 
evidences of blood-poisoning. Occasionally extravasations of blood occur 
in and under the skin, like those in internal organs. The pallor of the skin 
which diphtheritic anaemia and toxaemia produce in and after the second 
week is known to all who have had experience with this disease. 

The anatomical characters and symptoms pertaining to the nervous sys- 
tem and kidneys will be treated of at length in our remarks on Albuminuria 
and Paralysis. Albuminuria and paralysis, whether we regard them as 
symptoms, complications, or sequelae, occur so frequently and are of such 
grave import that it is proper to treat of them at length. They are the 
most important of the phenomena pertaining to the symptomatology of 
diphtheria. 

Albuminuria. 

It is perhaps remarkable that numerous epidemics of diphtheria had been 
observed before it became known that albuminuria is a common accompani- 
ment of it. The fact that the kidneys are affected so as to give rise to albu- 
minous urine was discovered by Mr. Wade of Birmingham, England, in 1857. 
The interesting paper communicating his discovery was published in the 
Midland Quarterly Journal of Medicine, 1857. Immediately after its 
appearance the subject to which he drew attention was fully investigated in 
different countries, and in the same year Mr. James published his observa- 
tions in the Medical Times and Gazette. In the following year (1858) two 
noteworthy papers appeared on the same subject, one by MM. Bouchut and 
Empis, read before the Parisian Academy of Sciences and published in the 
Gazette des Hopitaiix., and another by Germain See, and read before the Soci- 
ete des Hopitaux. Since 1858 monographs and reports of cases too nume- 
rous to mention have been published, so that the literature of diphtheritic 
albuminuria is quite full. 

As to the frequency of albuminuria in diphtheria, Bouchut and Empis 
found it in two-thirds of their cases, Germain See in one-half of his, and 



ALB LWIXURIA. 393 

Sanne in 224 cases out of 410. In New York City, where diphtheria has 
been many 3'ears naturalized or endemic. I made in the years 1875 and 1876 
daily examinations of the urine in 62 consecutive cases, and found it present 
in 24, while 38 were recorded exempt. But the proportion of cases as 
stated in my statistics is probabl}" below the truth, for the albuminuria is 
sometimes transient, and it often occurs as a mere trace and is liable to be 
overlooked. Its duration is frequently not more than from one to three 
days, and in the majority of instances it does not continue longer than ten 
days ; but we are all familiar with cases in which it continues fifteen or 
twenty days, or even for months. 

The date of the commencement of albuminuria varies greatly in different 
cases. Perhaps the largest number of observations bearing on this point are 
those of Sanne. In 224 cases albuminuria was detected on the first day of 
diphtheria in 8, on the second day in 10, on the third day in 30, on the fourth 
day in 30, on the fifth day in 22. From the sixth day to the eleventh the 
number on each day in whom albuminuria was present for the first time 
varied from 10 to 33. After the eleventh day there were only 9 new cases, 
and after the fifteenth day only 1 new case. Hence from these statistics we 
infer that there is little danger that albuminuria will occur after the second 
week if the patient have exhibited no symptoms of it previously. 

The amount of albumen in the urine varies greatly in different patients, 
from a slight cloudiness, scarcely visible after boiling, to so large a quantity 
that it becomes semi-solid by the application of heat or nitric acid. When 
the proportion of albumen is very large, there is also usually a notable dimi- 
nution in the quantity of urine passed. In ordinary cases the percentage 
of albumen varies at different times. It sometimes disappears during one 
or two days, and we are led to think that the patient is rapidly recovering, 
but its reappearance in full quantity shows that the apparent improvement 
was due to some transient cause. " Nothing," says Sanne, '■ is more irregu- 
lar than the course of diphtheritic albuminuria. At one time the precipitate 
is sudden, abundant, and flocculent; at another it commences with an opaque 
cloud, and continues with this characteristic till the time at which it disap- 
pears." Diphtheritic albuminuria differs in many respects from that in scar- 
let fever. The urine at first, when the renal disease is active, sometimes 
presents a pinkish tinge, and the microscope reveals the presence of red blood- 
corpuscles, but afterward, and in mild cases from the first, the urine exhib- 
its nearly the normal appearance, even when very albuminous, in contradis- 
tinction to its cloudy appearance in scarlet fever. The specific gravity is 
low, falling to 1010 or less, and casts, both granular and hyaline, are present. 
When the kidneys are seriously implicated the quantity of urine is usually 
notably diminished. G-reat diminution is a serious symptom, and it often 
precedes the fatal issue. 

In favorable cases the albuminuria does not in the average continue as 
long as in scarlet fever. The albumen may disappear from the urine in two 
or three days if its- quantity has been small, and in a large proportion of 
cases it disappears within ten days ; but cases occur in which albuminuria 
continues many months, with its final disappearance and the complete restora- 
tion of the health. Thus, a boy of six years treated by me had nephritis 
following a very mild attack of diphtheria. His urine in the first weeks was 
deeply tinged by the presence of red blood-corpuscles, but its quantity was 
normal, as determined by daily examinations, and it contained nearly or quite 
the normal amount of urea. Its specific gravity was at or under 1010. 
After a time the blood-corpuscles disappeared, the urine when not heated had 
its normal appearance, its specific gravity became normal, and the granular 
casts at first present disappeared. The patient was uniformly cheerful, was 



394 DIPHTHERIA. 

free from fever, his appetite was good, and no subjective symptoms occurred 
to indicate renal disease. Nevertheless, after the lapse of ten months a little 
albumen was still present in the urine. 

But the presence of albumen in the urine, if considerable, is an unfavor- 
able prognostic sign. Sanne states that in 233 cases of diphtheria accompanied 
by albuminuria 142 died and 91 recovered. In 160 cases in which albumi- 
nuria was absent, 63 died and 97 recovered. The statistics of others corre- 
spond with those of Sanne, so that the fact may be considered established 
that a larger proportion of cases of diphtheria with albuminuria perish than 
of those without albuminuria. It does not follow necessarily from this that 
the affection of the kidneys which produces the albuminuria contributes to 
the fatal result, for albuminuria is more frequent in grave cases than in those 
of a mild type. The termination in death may be due, and often is largely 
due, to other causes than the renal disease. 

Although severe and so-called malignant forms of diphtheria are more 
likely to be complicated by albuminuria than are mild forms of the disease, 
yet, as in scarlet fever, severe and fatal renal disease giving rise to albumi- 
nuria sometimes occurs in very mild cases of diphtheria. Several years ago I 
attended a child of six years with the following history : He had mild 
pharyngitis, with scarcely appreciable exudation and almost no constitutional 
disturbance. On the second day the patient seemed so nearly well that both 
the doctor and the intelligent grandmother who had charge of him did not 
think further medical attendance necessary. One week subsequently I was 
summoned to the child in haste on account of nearly complete suppression 
of urine. About one drachm was passed each time and at long intervals. 
This when heated became semi-solid. The late Prof. Austin Flint, who saw 
the case in consultation, and myself notified the family of the extreme grav- 
ity of the case and its approaching fatal termination — a prediction which was 
verified in forty-eight hours. In such rare cases, while the diphtheritic 
poison acts with great power upon the kidneys, producing a fatal nephritis, its 
influence is feebly felt in those tissues which are the usual seat of diphthe- 
ritic inflammation. Diphtheritic albuminuria is rarely attended by anasarca or 
by symptoms of uraemic poisoning. In 224 cases of diphtheritic albumi- 
nuria embraced in Sanne's statistics, dropsy occurred in only 7. Trousseau 
did not meet it oftener than in 1 case in 20. Its infrequency has been 
attributed to the fact that only one kidney or only portions of the kidneys 
have been affected, the sound portions performing sufficiently the excretory 
function. 

Oertel says : " The albuminuria of diphtheria is referable to many causes, 
of which the virus circulating in the blood is only one. Cardiac failure, 
respiratory difficulty, the febrile process, are adequate for the production of 
this symptom. The kidneys in cases where albuminuria has been present 
may be quite normal, or, on the other hand, they may exhibit varying 
degrees of parenchymatous inflammation." ^ The two common causes appear 
to be passive congestion of the kidneys, as of other organs, occurring during 
the dyspnoea of croup or from heart-failure, the albumen escaping from the 
over-distended renal veins, and parenchymatous nephritis, in which the tubules 
contain detached and disintegrating epithelial cells. In parenchymatous 
nephritis granular casts are commonly present. 

As regards prognosis, writers agree that diphtheritic albuminuria in itself 
does not tend to a fatal result in most cases, the unaffected portions of the 
kidneys, as stated above, being sufficient for the excretion of the deleterious 
products, especially the urea, whose retention in the system would involve 
danger. Therefore Sanne says " that diphtheritic albuminuria is an epi- 

^ Synopsis of Oertel' s monograph, London Lancet. 



PAEALYSIS. 395 

phenomenon which in the vast majority of cases remains without influence 
upon the course of the disease." But cases do occur, as we have seen by 
the history related above, in which fatal albuminuria, or fatal nephritis pro- 
ducing albuminuria, does take place as a complication or sequel of diphtheria. 
Unruh in 1881^ expressed the opinion that the albuminuria of diphtheria 
results from a simple transudation. But more exact microscopic examina- 
tions show that it is only in cases of croupal asphyxia or heart-failure that 
that degree of passive renal congestion occurs which leads to a transudation 
of serum. When there is no obstructed respiration, and no marked weakness 
of the pulse, the albuminuria is a result and symptom of infectious nephritis. 
Prof. Bouchard'^ states that infectious nephritis, whatever the cause or source 
of the infection, is a parenchymatous nephritis. Says he : " The kidneys are 
sometimes augmented in volume and weight. Their capsule has the ordinary 
appearance and adherence. The cortical substance appears sometimes gray- 
ish, sometimes congested and sprinkled with whitish tracts. The medullary 
substance preserves its normal aspect. In kidneys thus changed microscopic 
pathological anatomy reveals integrity of the tubes of Henle, catarrhal change 
of the straight tubes, and to a considerable extent of the convoluted tubes. 
In the convoluted tubes the epithelial cells remaining in place are swollen 

and sodden together. The cellular mass is entirely granular Not only 

are the convoluted tubes obstructed by granular cells, ?jut they are filled in 
some points by colloid matter or by blood. The glomeruli appear healthy, 
but we have seen the glomerular capsule distended with blood. In another 
case Renaut has seen it distended by colloid matter." Brault^ has observed 
in diphtheritic albuminuria intense congestion of the 'capillaries of the tubules 
and glomeruli, altered epithelial cells, and transuded blood-elements indicative 
of parenchymatous inflammation. 

Paralysis. 

Another very important symptom and sequel of diphtheria is paralysis. 
It has diagnostic and prognostic value. Writers in medicine prior to the 
sixteenth century were either ignorant of diphtheritic paralysis, or they 
vaguely alluded to it when they described the extreme debility which some- 
times accompanies or follows diphtheria. No clear and certain allusion to it 
has been discovered in medical literature until near the close of the sixteenth 
century. According to Sanne, Nicholas Lepois referred to it in 1580, and 
Miguel Heredia in 1690. Ghisi, in a letter describing the epidemic which 
occurred in Cremona on the north bank of the river Po in 1747—18, writes 
of his own son, who had paralysis in a severe form following diphtheria, '' I 
left to nature the cure of the strange consequences, .... which had been 
remarked in many wdio had already recovered, and which had continued for 
about a month after recovery from the sore throat and abscess. Puring this 
period this child spoke through the nose, and food, particularly that which 
was least solid, returned through the nares in place of passing down the 
gullet." In France also diphtheritic paralysis began to attract attention 
at or about the time when Ghisi in Italy wrote the above. Chomel in 1748 
described two cases, following what he designated gangrenous sore throat. 
The first patient, he says, had not quite commenced convalescence at the 
forty-fifth day of the disease, having still difiiculty in articulating, speaking 
through the nose, and having the uvula pendulous. In the second case the 
patient became squint-eyed and deformed, but day by day as his strength 
returned he regained his natural appearance. 

1 Jahrh. fur Kinderheilk. 2 j^^^.^^ ^g Medecine, 1881. 

^Jour. d'Anat. et de PIn/s., Nov., 1880. 



396 DIPHTHERIA. 

In America, in 1771, Dr. Samuel Bard of New York also related a case 
of this form of paralysis : A girl of two and a half years had recovered from 
a diphtheritic sore throat, and a diphtheritic pseudo-membrane upon the skin 
following the application of a blister had disappeared, when her convalescence 
was retarded by paralytic symptoms. " Whenever," says Bard, " she attempted 
to drink she was seized with a fit of coughing, yet she was able to swallow 
solid food without any difficulty. She improved, but in the second month 
she could scarcely walk or raise her voice above a whisper." 

From the time of Chomel, Ghisi, and Bard more than half a century 
elapsed during which diphtheritic paralysis attracted little attention, though 
Jurine and Albers alluded to it in 1809. It cannot be doubted that cases 
occurred in this long period wherever diphtheria prevailed, but it might have 
been of such a type that the paralysis was infrequent, for Bretonneau, 
although he was familiar with Ghisi's and Bard's writings, did not recollect 
that he had seen a case of diphtheritic paralysis prior to 1843. Although a 
close observer of diphtheria, the paralysis had not been observed by him, or 
at least had not attracted his attention, until it occurred in the person of his 
townsman, Dr. Turpin, in 1843. Twelve years subsequently, in 1855, Bre- 
tonneau had niade a sufficient number of observations to convince him that 
diphtheria frequently gave rise to a peculiar form of paralysis, and in his 
writings of this year he called the attention of physicians to this fact. But 
the opinions expressed by the eminent physician of Tours did not gain gen- 
eral acceptance until his friend and admirer Trousseau, at first distrustful of 
the existence of such a paralysis, had made a series of observations which 
fully established in his mind the theory of Bretonneau. His remarks on this 
subject, published in his Treatise on Clinical 3Iedicine, are interesting, as 
showing how gradually important truths are revealed in medicine. He had 
seen as far back as 1833 a marked case in the service of Becamier in the 
Hotel-Dieu, and another equally severe and typical case in 1846, but it was 
a long time before he recognized this ailment as one of the effects of the 
diphtheritic poison. Says he, speaking of the cases seen in 1833 and 1846: 
" They were a dead letter to me, yet I was acquainted with the case described 
by Dr. Turpin of Tours. Bretonneau related it to me, and said that it was 
a case of diphtheritic paralysis. The statement seemed to me incredible. I 

refused to see anything more in the case than a coincidence It was 

not till about the year 1852 that, enlightened by new cases better studied 
and better interpreted, I understood diphtheritic paralysis as Bretonneau under- 
stood it. From this time, whenever an opportunity occurred, I in my turn 
called the attention of my colleagues to this important subject." The clinical 
teachings and observations of Bretonneau and Trousseau were widely read, 
and the profession throughout the world soon recognized the fact that diph- 
theria often gives rise to a form of paralysis which, if not peculiar to it, is yet 
rare in other infectious diseases. Since these observations of Trousseau were 
published many observations have been made and many monographs on 
diphtheritic paralysis have been written by such men as Boger, Germain See, 
Herman Weber, Charcot and Vulpian, Gubler, Landouzy, Suss, H. von 
Ziemssen, A. Jacobi, and W. H. Thomson. But the nature of the paralysis 
and the manner in which it occurs are still undetermined. The fact that 
there is such a paralysis was slow in gaining acceptance in the minds of 
physicians, and so the cause and pathology of the paralysis are still not fully 
ascertained. 

Clinical History. — The statistics of diff"erent writers vary in regard to 
the frequency of diphtheritic paralysis. Probably it is different in different 
epidemics, and some observers may overlook the milder cases, which soon 
recover, and which are indicated by a slight impediment in swallowing and a 



PARALYSIS. 397 

slight nasal intonation of the voice. We may accept, as approximating the 
truth as regards its frequency, the following statistics of well-known and 
painstaking clinical instructors, who would be likely to detect the mildest 
forms of paralysis. In 937 diphtheritic cases observed by Cadet de Gassi- 
court, paralysis occurred in 128 ; 16.6 per cent, of Roger's cases of diphthe- 
ria had paralysis, and 11 -per cent, of Sanne's cases. 

But it must be borne in mind that, since paralysis is in most instances 
post-diphtheritic, those severe cases which are speedily fatal from blood-poi- 
soning or croup do not live long enough to suiFer from it, and such cases 
would be more likely to have the paralysis, if they lived, than the milder 
cases which recover. Hence it has been estimated that, if all diphtheritic 
patients lived sufficiently long, one in every four, or even one in every three, 
would exhibit paralytic symptoms. 

Time of Commencement. — In most instances the paralysis does not begin 
until the period of apparent convalescence from diphtheria and the pseudo- 
membrane has nearly or quite disappeared. Sanne says it most frequently 
appears from eight to fifteen days after recovery, the limit perhaps extending 
to thirty days, but he adds that it may appear from the fifth to the eleventh, 
and even as early as the second or third, day of diphtheria. Cadet de Gassi- 
court states that in twenty of his cases the paralysis began before the disap- 
pearance of the pseudo-membrane, most frequently about the seventh or eighth 
day of diphtheria. In two it commenced on the third day, and once in a 
prolonged diphtheria it began as late as the thirty-fifth day, the pseudo-mem- 
brane still being present. Usually, according to my observations, when paraly- 
sis follows diphtheria the nasal voice and some impediment in swallow^ing are 
observed early in the stage of convalescence, and at a later period muscles 
remote from the fauces may or may not be affected. Dr. L. E. Holt exhib- 
ited to the New York Clinical Society in December, 1887,^ a child of two 
years who had diphtheria in August and a second attack in the middle of 
October. She convalesced slowly, and in her ^convalescence had no paralytic 
symptoms, except a nasal voice, until December 1, when multiple paralysis 
sudd-enly developed. A brother of this patient also had diphtheria in Octo- 
ber, moderately severe, and early in convalescence paralysis of the muscles 
of the palate began, followed by that of other muscles, but it was not until 
the middle of December that the lower extremities were paralyzed. These 
cases are examples of the usual mode of commencement and extension of 
the paralysis. 

Diphtheritic paralysis is, therefore, with few exceptions, a late symptom 
of diphtheria or a sequel ; but Dr. Boissarie ^ has related cases in which the 
paralysis was not preceded by the ordinary symptoms of diphtheria, and 
which, so far as I am aware, are unique. An officer in the police had been 
ailing two or three days : he had a nasal voice and drinks returned through 
the nose. On inspection the velum palati was found insensible and motionless, 
but the fauces were otherwise in their normal state. In the hospital along- 
side the barracks in which the above case occurred a young man without 
fever, redness, or swelling of the fauces had also a nasal voice and return of 
liquid food through the nose. The porter of the hospital was similarly 
affected, and the doctor stated that certain other patients in like manner pre- 
sented symptoms of paralysis without the history of an antecedent diphtheria. 
Dr. Reynaud, called in consultation, expressed the opinion that the paralysis 
had a diphtheritic origin ; and this opinion was strengthened by the occur- 
rence immediately afterward of an epidemic of diphtheria in the place where 
these cases occurred. It appeared as if the diphtheritic poison had attacked 
the kidneys without manifesting its action in any other part of the system. 

^ New York Medical Journal, Dec, 1887. ^ Qazetle hebclomadaire, 1881. 



398 DIPHTHERIA. 

Certainly, such remarkable cases should have been more minutely examined. 
It is remarkable, inasmuch as diphtheria is so widely spread and so closely 
studied, that if paralysis is sometimes the only manifestation of the operation 
of the diphtheritic poison, other similar cases have not been observed and 
reported. It is, in my opinion, more probable that in the above cases diph- 
theria had occurred of so mild a form that it escaped notice. I have related 
elsewhere a case in which diphtheritic albuminuria was preceded by diphtheria 
of so mild a form as regarded the usual manifestations that it nearly escaped 
detection, and yet the renal complication or sequel was so severe that death 
resulted. In another instance a little girl, not complaining of herself, left a 
call for a visit to her brother, whom I found with diphtheria of rather a 
severe type. At the time of my visit she was playing with other children in 
the street, and it occurred to me to call her in and examine her throat. To 
the surprise of the family, the characteristic diphtheritic patch was observed 
over one tonsil. Such mild walking cases are not infrequent in New York 
City, where diphtheria, established for many years, is constantly present, 
sometimes pernicious and speedily fatal, but in other instances having a type 
at the extreme of mildness and with no evidence of blood-poisoning. All 
physicians who have had much experience with diphtheria, as in localities 
where it is naturalized or endemic, can recall cases in which a sequel of diph- 
theria, such as paralysis or albuminuria, has led to an accurate diagnosis of 
a pre-existing throat affection which was so mild that its true nature was not 
suspected. In this respect diphtheria resembles scarlet fever, which also 
presents an equally variable type from extreme mildness to a fatal severit3^ 
Hence it seems probable that in Boissarie's cases diphtheria of so mild a 
form that it escaped notice had preceded the paralytic manifestation. 

The paralysis, as a rule, affects both motor and sensory nerves. Thus in 
paralysis of the velum and pharynx anaesthesia more or less marked occurs 
of the velum, the isthmus of the fauces, and the walls of the pharynx, in 
addition to the motor paralysis. In the more severe cases anaesthesia with 
absence of reflex action occurs not only over the entire pharynx, but also 
over the epiglottis. The combination of motor and sensory paralysis should 
be borne in mind in studying the cause and nature of the ailment. The 
muscles affected by diphtheritic paralysis atrophy as in other forms of 
paralysis. Dr. H. von Ziemssen^ says that such marked atrophy does not 
occur in any other disease, except in acute poliomyelitis and saturnine 
paralysis. 

The symptoms and course of diphtheritic paralysis vary according to its 
location and the muscles affected. Therefore we will sketch the clinical his- 
tory of its various forms separately, beginning with that which is first in 
time, most frequent, and least dangerous : 

1. Loss of the Tendon ReJBLexes. — In 1882, Dr. Buzzard made the 
observation that the knee-jerk is absent in cases of diphtheritic paralysis. 
Bernhardt stated that loss of knee-jerk may precede other nervous symptoms, 
or may occur without other symptoms indicating impairment of the nervous 
system. He also stated a fact, now generally admitted, that the loss of knee- 
jerk may have diagnostic value in indicating the diphtheritic nature of a pre- 
existing obscure disease. But the profession in this country had little know- 
ledge of the loss of the tendon reflexes in diphtheria until Prof. B. L. McDon- 
nell of the Montreal Greneral Hospital read a paper on this subject before the 
Canada Medical Association, August 31, 1887. and published it in the Medical 
Neim of Philadelphia in the following October. Dr. McDonnell's observations 
relate to 18 cases of diphtheria admitted into the General Hospital. Of 
these 18 patients, 10 had loss of knee-jerk at the time of admission, while 

^ Klinische Vortrdge, 1887, No. iv. ^ Virchoiv's Archiv, Bd. xcix. 



PABALYSIS. 399 

in the remaining 8 it was present. The cases observed by the doctor were 
sufficient, he believed, to enable him to make the following statement : Knee- 
jerk in many cases of diphtheria is absent from the very first day of the illness. 
It is a noteworthy fact- that in most of the cases detailed by McDonnell in 
which there was loss of the tendon reflex other forms of paralysis subse- 
quently appeared. 

Since the publication of Dr. McDonnell's paper many observations have 
been made confirmatory of his statement. At a meeting of the New York 
Clinical Society, held December 23, 1887, Dr. L. E. Holt exhibited a brother 
and sister of five and two years with multiple paralysis who had lost the 
knee-jerk, and the examination of one of them showed complete loss of the 
plantar reflex. Since the attention of the profession has been directed to the 
loss of the tendon reflexes, all observers admit that it is not only the earliest, 
but also the most frequent, of the paralytic symptoms, probably occurring in 
one-third to one-half of all cases under treatment. Dr. Angel Money, in a 
discussion before the London Clinical Society, September, 1887, stated that 
he had observed an initial increase of the knee-jerk preceding its abolition. 
Dr. H. von Ziemssen remarks that, while the tendon reflexes are so often lost, 
the cutaneous reflexes are frequently exaggerated. 

The loss of the tendon reflexes, while, as we have stated, it is the first in 
time of the paralytic symptoms, appears also to have the longest duration. 
In cases of multiple paralysis it seems to be the last to disappear. Thus, 
Dr. McDonnell states that the loss of knee-jerk in a boy of fourteen years 
continued four months, and in his two sisters it was still present when all 
other symptoms of the disease had disappeared. 

2. Palatal Paralysis. — "With the exception of the loss of the tendon 
reflexes the most common form of diphtheritic paralysis is that in which 
the velum palati and muscles of the pharynx are afiected. This form of 
paralysis is revealed by a nasal intonation of the voice, slow speech, snoring 
during sleep, difficult deglutition, and return- of liquids through the nares. 
As the paralysis increases in severity and extent, and the palato-glossus and 
constrictor muscles of the pharynx become paralyzed, the difficulty in swal- 
lowing increases. The patient finds it necessary to throw his head backward 
in swallowing and to swallow slowly and in small amount. The food descends 
in the oesophagus by its weight, and with but little aid from the pharyngeal 
muscles. On examining the fauces we discover the velum relaxed and 
motionless, and the uvula, deprived of its tonicity, drops on the base of the 
tongue. On touching the uvula with the point of a pen or pencil it is found 
to be insensible, no reflex action occurring. Sensory paralysis occurs, as a 
rule, in typical cases, the patient experiencing no pain when the parts are 
pricked with a pin or other instrument. The fauces should be inspected and 
tested from day to day in order to determine the progress of the paralysis. 
In mild cases it may be limited to the velum and palate, but it frequently 
extends to the epiglottis and upper part of the larynx, so that in attempts to 
swallow portions of the food enter the larynx, exciting a cough. The affected 
muscles may regain their use in less than a week, but frequently from one to 
two months elapse before their function is restored. 

Palatal paralysis terminates favorably with few exceptions, if the patients 
are otherwise in good condition, but if there be much prostration from the ante- 
cedent diphtheria and from the dysphagia, death may occur from inanition. 
Cadet de Gassicourt has cited two cases of death from this cause, although 
life was probably prolonged b}^ feeding by means of an oesophageal tube intro- 
duced through the nostrils. Rarely, also, death has occurred from the descent 
of food into the air-passages and the plugging of a bronchus. Tardieu and 
Peter have each related a case of this mode of death. As a chief function 



400 DIPHTHERIA. 

of the velum palati is to close tlie posterior nasal fossae during deglutition, 
food, especially if liquid, is liable to be returned througk the nostrils until 
the function of the velum is restored. 

3. Multiple Paralysis. — This form of paralysis is commonly preceded by 
loss of the tendon reflexes. In most instances it begins with loss of power in 
the muscles of the palate, but exceptions occur. Cases are reported in which 
the muscles of the eye, those of motion and of accommodation, are first para- 
lyzed, the palatal muscles being unaffected or subsequently attacked. Trous- 
seau has stated that in cutaneous diphtheria the first loss of muscular power 
is sometimes in the lower extremities instead of in the palate ; and other 
observers have recorded cases in which multiple paralysis commenced in one 
or more of the extremities. Therefore the order of the paralytic seizures 
diJffers in different cases, and muscles are affected in one patient that escape 
in another. The degree of paralysis varies in different muscles. In some 
the loss of power is complete, while in others it is partial. When the lower 
extremities are entirely motionless the patient frequently has considerable 
use of the upper extremities. 

Even in the severest cases many groups of muscles entirely escape. 
Therefore I prefer the term multiple paralysis to the term general paralysis 
employed by some writers to designate this form of the disease. 

Trousssau speaks of what he designates the mutability of diphtheritic 
paralysis. He says the paralysis which occupies one limb disappears in this 
limb to manifest itself in another. " The numbness, for example, which the 
patient has been experiencing in one leg will suddenly cease, and become 
greater in the other leg. To-day the right hand will not give a dynamomet- 
ric pressure of more than ten to twelve kilogrammes, and to-morrow its power 
will have augmented, while that of the left will have diminished ; then the 
parts which were first affected are a second time attacked and become more 
affected." Even the dysphagia may vary on different days, as Cadet de G-as- 
sicourt has stated. He relates the case of a child of three and a half years 
in whom the velum palati suddenly resumed its function : the head, which 
had dropped from paralysis of the muscles of the neck, became erect, the 
patient was able to sit, and the upper extremities recovered their power, but 
the improvement was of short duration, the paralysis returning as at first. 
These sudden and unexplained variations in the degree of paralysis resemble, 
says Trousseau, the mutability of paralysis in hysteria. Among the most 
noteworthy of the paralyses resulting from diphtheria are those pertaining to 
the eye. The media and retina are unaffected, but the levator palpebrse, the 
muscles of accommodation, and the motor muscles of the eye are paralyzed 
in certain patients, so as to cause dropping of the eyelids, strabismus, and 
indistinct vision. In addition to the muscles already mentioned, various 
muscles of the trunk, of the neck, the sphincter ani, and the sphincter 
vesicae are sometimes paralyzed, producing deformity and incontinence of 
urine and feces. The paralysis of the muscles of accommodation is usually 
such that patients become presbyopic, seeing distinctly distant, but not near, 
objects. 

The muscles of the face are also occasionally paralyzed. Many observers 
have related cases of facial hemiplegia. When general paralysis of the facial 
muscles occurs — fortunately, a rare event — whatever the mental state, -how- 
ever great the excitement, the features are entirely devoid of expression ; the 
aspect is dull and idiotic ; the face is flabby and motionless ; the lids and lips 
droop ; saliva flows from the mouth ; and speech is slow and difficult. At 
the same time, the mental faculties, though deprived of the usual mode of 
expression, are sound and active. 

But the most accurate idea of the symptoms of multiple paralysis can be 



PARALYSIS. 401 

imparted by the narration of a case, and I select for this purpose the graphic 
description of this form of paralysis published by Dr. C. W. Fallis in the Jled- 
ical Summari/ for January. 1888. He describes the ailment as it occurred in 
his own person, as follows : •• About three weeks after the subsidence of the 
disease [diphtheria] the paralytic symptoms began to show themselves. Im- 
paired vision was the first trouble noticed, inability to accommodate the eyes 
TO near objects, and in taking up the paper to read one morning I found I 
could scarcely see a word, and soon after, although distant objects could be 
seen as well as ever, high-power glasses were required to read any kind of 
print. Double vision was noticed afterward. At about the same time numb- 
ness of the tongue was felt : the muscles of deglutition became paralyzed, so 
that swallowing was attended with strangling and regurgitation of food 
through the nose. There was a rapid pulse. 120 to the minute, showing that 
the pneumogastric was involved. Weakness of the limbs, causing a stagger- 
ing gait, appeared ; fingers became weak and numb, so that small objects 
could not be picked up. the symptoms becoming worse and worse as the dis- 
ease progressed. The muscles of the left side of the face became affected 
with all the symptoms of facial paralysis from organic disease. Motion 
became more and more impaired, till I could neither stand nor walk, and 
when at the worst I was perfectly helpless, could not feed myself, had to be 
lifted from chair to chair, turned in bed, and could not even lift my hand to 
my head or throw one limb over the other. Sensation was so impaired that 
hands and feet felt like lifeless weights, and in the dark I could not tell 
whether my feet were on the floor or not. The muscles of respiration were 
at no time affected to such an extent as to render breathing difficult, and the 
power of perfect speech was retained. Paralysis of the bowels necessitated 
the use of warm-water injections to promote their action. Some of the symp- 
toms abated, while others became more aggravated, those first to appear being 
generally the first to subside : however, the smaller-sized muscles recovered 
rajDidly. while the large fleshy ones were more tardy in reaching their normal 
state, the facial paralysis lasting but a few days, while locomotion was either 
labored or impossible for many weeks. The course of the disease from the 
beginning to the worst stage was about nine weeks, when it remained station- 
ary for two weeks. Improvement was at first very slow and tedious, but 
after I could walk a little it was much more rapid, and by the fifteenth week, 
with the exception of some weakness, I was well." 

Multiple paralysis not infrequently continues from two to six months. 
As might be expected, the prognosis is less favorable when the paralysis is 
multiple than when it is restricted to the velum and pharynx. In 13 cases 
observed by Cadet de Grassicourt, 6 died. 

4. Cardiac Paralysis (the cardio-pulmonan/ parali/sis of certain French 
writers). — In cases of the first, second, and third forms of paralysis which 
have been considered above the vital organs are not directly, involved. 
These paralyses, however inconvenient they ma}" be, are not directly fatal. 
The paralysis which we are about to consider presents a very different clin- 
ical aspect, inasmuch as the organs aff"ected are among the most important 
in the system, a serious impairment of their functions rendering death inevi- 
table. 

Physicians who have had experience in the treatment of diphtheria have 
met cases in which symptoms, usually of sudden development, indicated 
dangerous heart-failure. Perhaps the patient has been gradually improving, 
the pseudo-membrane has nearly or quite disappeared, the temperature is 
not far from normal, the swallowing is better and more nutriment is taken, 
the family are cheerful in the prospect of a speedy recoverv. and the phy- 
sician expects soon to discharge the patient cured. Suddenly the scene 
26 



402 DIPHTHERIA. 

changes. The pulse becomes feeble and abnormally slow or rapid — it is 
usually at first slow and subsequently rapid — the respiration is superficial, 
and the surface becomes pallid, often slightly cyanotic. In the more favor- 
able of these cases the patient may rally by active stimulation, and perhaps 
he eventually recovers, or after some hours or a day or two of comparative 
comfort he succumbs to a return of heart-failure. There is no other disease 
in which these sudden, unforeseen, and fatal attacks of heart-failure occur so 
frequently as in diphtheria. There is no other disease in which physicians 
are so frequently deceived in their prognosis for various reasons, but largely 
on account of the occurrence of these unexpected attacks of heart-weakness. 

But a clear and accurate idea of the clinical history of these cases of 
sudden heart-failure can be best imparted by the relation of typical cases. 
For this purpose I will briefly narrate cases occurring in the hospital service 
of one of the most trustworthy clinical teachers of the present time, M. 
Cadet de Gassicourt, though I believe that all physicians who have been sev- 
eral years in practice where diphtheria is prevailing can recall to mind cases 
equally striking and typical. I select his cases on account of the complete- 
ness of his records : 

A child of two years entered Cadet de Gassicourt's service on January 
3d with diphtheritic pharyngitis of ten days' continuance. The tonsils were 
large, still covered with pseudo-membrane, and the submaxillary glands were 
also enlarged. He had no laryngeal symptoms and his urine was without 
albumen. On the following day the velum and pharyngeal muscles were 
slightly paralyzed, the speech nasal, and deglutition moderately embarrassed. 
He was quiet during the night of January 4th and in the morning of the 5th, 
but at ten a. m. he became chilly, his face and extremities feebly cyanotic, 
and slight dyspnoea and dilatation of the alee nasi were observed. His pulse, 
at first abnormally slow, became rapid; he was agitated, uttered loud screams 
of distress, and fell back cyanotic and dead. The death-struggle did not 
occupy more than one minute. Another infant, also two years of age, 
entered the same service, having diphtheritic pharyngitis of two days' con- 
tinuance. The fauces presented the usual red appearance, the tonsils were 
swollen and covered with a thick exudate, but there was no albuminuria nor 
croupiness. Two days later the pseudo-membrane had diminished, but the 
velum palati was paralyzed. On the following day the general appearance 
was satisfactory and the pseudo-membrane had still further diminished. At 
eight P. M. the infant was suddenly seized with vomiting, accompanied with 
great dyspnoea, rapid pulse (160), and a cyanotic hue of the face and 
extremities. He was restless and uttered cries of distress. Two hours later 
he screamed loudly, raised himself in bed, and fell back dead. A child of 
five years was admitted with diphtheritic pharyngitis of two days' continu- 
ance, having enlarged tonsils covered with pseudo-membrane, and enlarged 
cervical glands, but without cough or albuminuria. Seven days later, the 
ninth of the disease, the pseudo-membrane had disappeared, but the velum 
palati was paralyzed. On the following day there was little change, except 
occasional vomiting, but the general state was good and sleep tranquil. At 
seven A. m. on the following day, the eleventh of the disease, after a calm 
night, the child uttered two or three cries, the pulse became rapid, the respi- 
ration embarrassed, the features, extremities, and finally the entire surface, 
cyanotic, and at eight a. m. death occurred quietly. 

The similarity of these three cases is apparent. Paralysis of the velum 
and palate had continued in the first case eighteen hours, in the second case 
thirty-six hours, and in the third case forty-eight hours, when suddenly the 
heart and lungs were greatly embarrassed in their functions, and death occur- 
red within one hour from the commencement of the severe symptoms. The 



PARALYSIS. 403 

agitation, repeated cries of distress, and the shrill cr}^ that preceded death 
indicated extreme suffering. 

Severe pain, praecordial, epigastric, or abdonainal, is present in some if 
not in most of these cases of sudden heart-failure, as we shall see from others 
presently to be related. It was probably experienced by these three patients, 
who were too young to express clearly their subjective symptoms. 

Gombault made a minute microscopic examination of the affected organs 
in these three cases after the tissues had been properly hardened by chemical 
agents. In one of the cases he examined the pneumogastrics and myo- 
cardium, and both were found in their normal state. As regards the nervous 
centres, the anatomical changes were alike in all three. In the spinal cord 
lesions were found at the origin of the anterior roots of the spinal nerves, 
characterized by fragmentation of the medullary substance in the nerve- 
fibres, numerous granules and minute globules appearing in this substance 
and occupying its place. 

In addition to this, undue swelling of the axis-cylinders was observed. 
In the three cases the gray substance in the anterior cornua had undergone 
a sort of rarefaction, the microscopic sections being more transparent and the 
elements in the section being wider apart than in the normal state. No 
meningitis or injury of the blood-vessels was observed in the spinal columns, 
but numerous nerve-cells were deprived of their prolongations. The medulla 
oblongata, the centre and source of the nervous supply to the heart, lungs, 
and stomach through the pneumogastrics, was also carefully examined in the 
three cases. Nothing abnormal was observed in .this organ, except small 
masses of leucocytes in the vessels. The substance of the medulla oblongata 
and the nerve-fibres constituting the roots of the pneumogastrics seemed 
healthy. The small masses of leucocytes in the blood-vessels were not 
sufiicient to obstruct the circulation, and the appearance of the blood-cor- 
puscles was normal. Hence, in the opinion of Grombault, the small aggrega- 
tions of leucocytes in the vessels had no effect on the innervation of the 
thoracic organs derived from the medulla. The points of special interest in 
the microscopic examination of the three cases were the apparently healthy 
and normal state of the pneumogastrics and myocardium in the one case in 
which they were examined, and of the medulla oblongata in the three cases, 
while the gray matter of the spinal cord, which has no immediate nerve-con- 
nection with the heart, showed marked degenerative changes. 

The above are striking examples of sudden and fatal heart-failure occur- 
ring during apparent convalescence, when the symptoms of diphtheria 
appeared to be abating, with the exception of the paralysis of the velum 
and palate. The following cases presented a clinical history in some respects 
different : A child of eight years had been under treatment for diphtheria 
since February 9, 1883. On February 20th the membrane had disappeared, 
but slight paralysis of the velum and left upper extremity was observed and 
the urine contained a little albumen. At three P. M. she was seized with 
severe abdominal pains, followed by vomiting, slow respiration, slow and 
feeble but regular heart-beat, imperceptible pulse, coolness of surface, and 
cyanosis. These symptoms increased, and at half-past six p. m. death occurred. 
The clinical history differed from that in the three cases related above in the 
fact that there was no agitation or moaning at the close of life, and that the 
heart-beat remained abnormally slow unless during the last moments. In 
another case paralysis of the velum and palate began on the third day of 
diphtheria, while the pharyngeal and nasal inflammations were in full activity. 
The urine was slightly albuminous. Three days subsequently, in the morn- 
ing, the muscles of the nucha and right shoulder were paralyzed. At two 
P. M. the child complained of violent abdominal pains, followed by nausea 



404 DIPHTHERIA. 

and vomiting. The vomiting was partially relieved, but dj^spnoea and a rapid 
lieart-beat followed. The cyanosis increased until it extended over the entire 
surface, and death occurred three hours after the commencement of symp- 
toms referable to heart-failure. A boy of five years had diphtheritic croup, 
for which tracheotomy was performed and the canula inserted. He subse- 
quently did well for a time, but afterward lost his appetite. On the eleventh 
day of the disease he had paralysis of the velum and palate. On the twelfth 
and thirteenth days the disease seemed to be stationarj^ and the child Avas 
quiet. Suddenly, at seven p. m. on the thirteenth day, multiple paralysis 
occurred. Liquid food taken by the mouth was returned in part through 
the nostrils, and a part entered the larynx and escaped from the tracheal 
opening. An hour later the muscles of the nucha, the arms, and both sides 
of the trunk were paralyzed and the head dropped. At seven a. m. on the 
following day vomiting, dyspnoea, cyanosis of the face and extremities, and a 
very rapid pulse occurred. ■ The asphyxia increased, the pulse grew more 
feeble, the surface cool, and death took place three hours later. 

Cases like the above are not infrequent in severe epidemics of diphtheria, 
but in some instances the loss of power in the heart occurs more gradually. 
A boy of twelve years had diphtheritic pharyngitis from which he was 
apparently convalescing. Some days after the disappearance of the inflam- 
mation the velum palati and muscles of the pharynx were paralyzed. Then 
succeeded paralysis of the muscles of the nucha, of the muscles of accom- 
modation, and of those of the upper and lower extremities. The march of 
the paralysis was for a time progressive. Then it seemed to recede, but the 
improvement did not continue. One month from the commencement of diph- 
theria the child uttered plaintive cries, became motionless as if from general 
paralysis, and a state of asphyxia slowly occurred, accompanied by cyanosis. 
During the following night the patient lay in a stupor, and on the ensuing 
morning the features presented a cadaverous and slightly cyanotic hue, the 
extremities were cool and blue, the tongue pallid, moist, and of a normal 
warmth, the respiration hurried and without auscultatory signs of disease, 
the pulse feeble and rapid (148). Finall3^ the sphincters were paralyzed, the 
urine and feces escaping involuntarily. Within ten minutes after the above 
notes were written the patient died of heart-failure. The feature of special 
interest in this case was the long continuance of multij)le paralysis when the 
cardiac and pulmonary symptoms occurred. 

Sudden heart-failure in diphtheria is usually fatal, but recovery is possi- 
ble. Cadet de Gassicourt in his large clinical experience met 1 recovery to 
14 deaths. This case is interesting, since the heart-failure preceded the palatal 
and other forms of paralysis, instead of being preceded by them, as is ordi- 
narily the case. Twenty days after the commencement of diphtheria, and 
when in apparent convalescence, the patient was seized with extreme pain in 
the prgecordial region, attended by a fall of pulse to 42. He had cold sweats, 
rigors, and vomiting. In one and a half hours these symptoms abated. 
Three days subsequently another similar attack occurred, and subsequently 
two others, but less severe than the first. On the twenty-eighth day from 
the beginning of diphtheria and eight days after the syncopal attacks par- 
alysis of the velum and pharynx began, soon followed by paralysis of the 
vocal cords, of the muscles of accommodation, and of those of the extremities, 
which continued three months, when recovery was complete. Cases of recov- 
ery from sudden and alarming symptoms of heart-failure have also been 
related by Sanne, Billard. and others. 

What is the cause of this sudden loss of power in the heart in diphtheria, 
occurring usually during apparent convalescence? Does it result from dis- 
ease in the muscular structure of the heart, from thrombosis or ante-mortem 



PARALYSIS. 405 

clots in the cavities of the "heart, or does it result from disease of the central 
organ of innervation, the medulla oblongata, or from disease and deficient 
conducting power m the important nerve which controls the heart's action, 
the pneumogastric, or in the branches which this nerve supplies to the heart 
as well as the lungs and the stomach ? — for these three organs appear in most 
instances to be affected simultaneously. 

Bouchut and Lagrave attribute sudden heart-failure in diphtheria to 
endocarditis ; and yet it is very seldom that a b^niit or heart-signs indicative 
of endocarditis have been observed during life. The belief in the ocurrence 
of this inflammation is based on the appearance of the free edge of the mitral 
valve, and sometimes of the aortic valves in addition. They have appeared 
roughened as if from the presence of minute vegetations. At the same time, 
the surface of the valves and the endocardial surface have undergone no 
appreciable change, such as an endocarditis would be likely to cause. Since 
the announcement of the theory of Bouchut and Lagrave and attention has 
been drawn to the subject, the roughened edge of the mitral and aortic 
valves, upon which their theory of an endocarditis as the causal agent 
of sudden heart-failure is based, has been found with equal frequency in 
children who have perished with other diseases. The late Prof. Parrot says 
Cadet de Gassicourt expressed the decided conviction that the roughening 
of the tips of these valves does not have an inflammatory origin, but is 
an anatomical peculiarity which originates in the foetal development. Sanne 
says in reference to Bouchut and Lagrave's theory, " My personal investi- 
gations are absolutely negative. Observations of diphtheria to the number 
of 149, taken in these later years, .... have not furnished a single case of 
endocarditis. I should fear to express myself in such a positive manner 
if I should trust to the simple testimony of my senses; but a large number 
of these patients were auscultated by Barthez and by D'Espine and Gom- 
bault The conclusion .... therefore is that diphtheritic endocar- 
ditis is extremely rare, as pathological anatomy and clinical observation alike 
demonstrate." Therefore the theory which attributed sudden heart-failure 
to endocarditis has not been sustained by recent observations, and does not 
appear to be tenable. 

Weakening of the heart's action in diphtheria, with sudden death as a 
consequence, has with more probability been attributed to granulo-fatty 
degeneration in the muscular fibres of the heart consequent upon a prolonged 
and severe diphtheritic attack. Oertel says : "When the general disease lasts 
long and is very intense, and especially in cases in which death is caused sud- 
denly by paralysis of the heart, the muscle appears pale, soft, friable, broken 
by extravasations of blood, and on microscopical examination most of its fibres 
are seen to be already in an advanced stage of fatty degeneration."^ Such 
degenerative changes, if occurring in a considerable proportion of the muscu- 
lar fibres of the heart, would inevitably render the contractile power of this 
organ feeble and perhaps inadequate. Still, if we regard it as a cause of 
sudden heart-failure,, it can be regarded as such in only a relatively small 
number of instances, for in most cases the weakening of the power of the 
heart is sudden and during convalescence — at a period, therefore, when degen- 
erative changes are not likely to occur. In most of the recorded cases the 
contractile power of the heart does not appear to have been notably weakened 
previous to the attack of heart-failure, as it would probably have been were 
degenerative changes in the myocardium the sole or chief cause. The clini- 
cal history is as if the heart were suddenly overpowered by an agent of rapid 
— never slow — development. Moreover, in typical cases of sudden heart- 
failure the microscope sometimes reveals a healthy myocardium, as in one 

^ Zierassen^s Cyclopcedia, vol. i. 



406 DIPHTHERIA. 

of the cases related above. We must look, therefore, for some other cause, 
although admitting that degenerative changes in the muscular fibres of the 
heart, when present, contribute to a weakened action of this organ. 

Sudden heart-failure in diphtheria has also been attributed to cardiac 
thrombosis ; but, as several writers have pointed out, the heart-clots are 
identical in appearance and kind with those found in the heart after death 
from other diseases than diphtheria. There is every reason for the belief 
that they occur during the death-struggle, and therefore are not the primary 
cause of the heart-failure, but are secondary or consecutive. 

Among the most strenuous advocates of the theory that cardiac throm- 
bosis is the common cause of sudden heart-failure and sudden death in diph- 
theria is Dr. Beverly Robinson, now a distinguished physician of New 
York, whose able thesis on this subject, published in 1871 when he was a 
resident of Paris, attracted much attention and is alluded to by nearly all 
recent French writers on this subject. But the oj)inion of most pathologists 
in reference to this theory is, I think, expressed by Cadet de Gassicourt in 
the following passages, published in his clinical treatise : " I have often 
shown you these clots, and I have enabled you to see that they occur equally 
in children who have died of diphtheria as well as in those who have suc- 
cumbed to other maladies, in subjects struck with sudden death, and in those 
who have not been attacked by any sudden casualty. This objection is in 
itself conclusive. You have been able to see also that the constitution of 
these clots does not have any of the characters which authors the most com- 
petent have assigned to clots formed during life : they are the clots of the 
agony.'' Sanne also writes in almost identical language. 

In searching for the cause of sudden heart-failure in diphtheria we must 
note the fact that, as a rule, in typical cases it is preceded by palatal and 
often multiple paralysis. The paralysis has continued for a time, extending 
perhaps from one group of muscles to another, when suddenly the heart 
passes under some powerful influence which restricts and overpowers its 
action. The theory of deficient innervation or a true cardiac paralysis 
appears most tenable under the circumstances. It afi'ords the most satisfac- 
tory explanation of those unfortunately not infrequent cases in which death 
suddenl}^ occurs during appareht convalescence from diphtheria, when the 
symptoms are fast disappearing, with the exception of the palatal or other 
paralysis. It afi'ords best of all the theories an explanation of the occur- 
rence of sudden death from heart-weakness in those obscure cases which 
have puzzled physicians — cases in which the post-mortem examination has 
revealed an apparently healthy state of the heart. The theory of an arrested 
or deficient innervation of the heart also furnishes an explanation of the 
occurrence of concomitant symptoms in these cases of sudden heart-failure 
— such symptoms as vomiting, epigastric pain, and dyspnoea or irregular 
respiration ; for the heart derives its innervation from the same source as 
the lungs and the stomach — that is, through the pneumogastric. For the 
reasons now given we feel justified, in our classification of the forms of 
diphtheritic paralysis, to make a distinct class having the designation cardiac 
jDaralysis, or, to adopt in our language the French expression, cardio-pulmo- 
nary paralysis. 

Etiology. — The four forms of diphtheritic paralysis — first, the abolition 
of the tendon reflexes, the most common, the earliest, and the least danger- 
ous of all : secondly, palatal paralysis, which may occur as early as the 
third day of diphtheria, but is most common during its later stages, or in 
the period of convalescence : thirdly, multiple paralysis, in which various 
muscles throughout the system are paralyzed ; and, fourthly, cardiac paraly- 
sis, the most dangerous of all — probably are produced by the same cause 



PARALYSIS. 407 

and have the same pathology in most instances. We may, therefore, in the 
following pages, in staclying the cause and nature of diphtheritic paralysis, 
regard the various forms which it exhibits as manifestations of one disease. 
What is true of cardiac paralysis as regards its cause and nature we may 
assume to be true in reference to palatal and multiple paralysis, and even the 
abolition of the tendon reflexes. The most dangerous and fatal paralysis, 
the cardiac, is, as we have stated above, in nearly all patients associated with 
the milder forms, showing that the same cause or causes are operative at the 
same time in the individual. 

Gubler, in his memoir published in 1860-61, attributed paralysis of the 
velum and palate to disease of the terminal nerves produced by contiguity 
or propagation from the inflamed fauces: and he held that the same injury 
of the nerves and paralysis might result from any anginose inflammation if 
severe enough. But this theory was short-lived, for physicians soon per- 
ceived that it was inadequate to explain the occurrence of paralysis at a dis- 
tance from the inflamed surfaces ; and palatal paralysis sometimes occurs 
after cutaneous and other forms of diphtheritic inflammation in which both 
the fauces and the nares have entirely escaped and remained healthy. 

Trousseau, impressed with the inadequacy of Grubler's theory, directed his 
attention to the nervous centres. He was led to believe, from the fact that 
the paralysis usually terminates favorably, and because in certain fatal cases 
he was unable to discover any lesion sufficient to produce the paralysis in 
the brain, spinal cord, or meninges, that it did not occur from any structural 
change in the nervous system. Trousseau, an unsurpassed clinical observer, 
was not a microscopist, and being unable to discover any anatomical cause of 
the paralysis, he relates" the case of the crew of a vessel who were paralyzed 
by eating an eel which contained some poisonous ingredient, and, after allud- 
ing to instances of paralysis resulting from smallpox, typhoid and typhus 
fevers, and cholera, continues : " Well, then, diphtheritic paralysis belongs 
to the same category : its real cause is the poisoning of the system b}' the 
morbific principle which generates the malady on which the paralysis depends, 
and in regard to the mode of action of which in producing the paralysis we 
shall always perhaps remain in ignorance." 

Since the time of Trousseau many eminent pathologists have endeavored 
to discover the anatomical characters and elucidate the nature of diphtheritic 
paralysis by patient and thorough microscopic examinations. \Ye have 
already detailed the microscopic appearance in Cadet de Grassicourt's three 
memorable cases. In 1862, Charcot and Yulpian stated that they had exam- 
ined the nervous filaments in the velum palati paralyzed by diphtheria, and 
found certain of them entirely free from medullary matter, granular bodies 
occupying its place ; but partial degeneration was more common. In some 
of the fibres the medullary matter was intact. Lionville in 1872 stated that 
he had found degenerative changes in the phrenic nerve of a patient who 
had died of asphyxia following an attack of diphtheria. The contents of 
certain of the fibreis constituting this nerve were amorphous, filled with 
granular bodies instead of the normal nerve-substance. Leyden in 1872 
discovered lesions in the peripheral nerves and in the central organ upon 
which he based his theory of an ascending neuritis. Roger and Damaschino 
in 1875 examined the nervous system in four children who had died of 
diphtheritic paralysis, and found atrophy of the nerve-fibres in the periph- 
eral nerves. The medullary matter appeared granular in certain points, 
and in others it had entirely disappeared, while the axis-cylinder was not 
notably altered. 

Such observations, to which others might be added, have fully established 
the fact of peripheral nerve-lesions, such as would be likely to result from a 



408 DIPHTHERIA. 

neuritis, in the paralysis of diphtheria ; but it must be borne in mind that 
the various observers, while they report degenerative changes' in certain of 
the nerve-fibres or tubes in the peripheral nerves of the paralyzed part, 
also state that others in the same nerves were to appearance normal and 
capable of performing their function. Such are the facts upon which the 
theory that diphtheritic paralysis is caused by peripheral nerve-lesions, a 
peripheral neuritis, is based. 

In the endeavor to elucidate the cause of diphtheritic paralysis attention 
has also, as might be expected, been directed to the state of the brain and 
spinal cord, and anatomical changes have been discovered in them quite as 
marked as in the peripheral nerves. Buhl, Roger and Damaschino, Pierret, 
Vulpian, Dejerine, and Oertel discovered in different cases in the brain and 
spinal cord in those who died of paralysis various anatomical changes, among 
which we may mention small extravasations of blood and slight softening in 
the cerebral substance, extravasations of blood and thickening of the neuri- 
lemma in the roots of paralyzed nerves (Buhl) ; endo- and perineuritis at the 
point of origin of the aff'ected nerves, thickening of the walls of the vessels 
and accumulation in them of white corpuscles (Pierret) ; rarefaction of the 
connective tissue and degenerative change in the nerve-cells in the anterior 
cornua of the cervical and upper dorsal region of the spinal cord (Vulpian) ; 
atrophy and granular degeneration and fragmentation of the myeline in the 
nerve-tubes in the anterior roots of the spinal nerve, increase of nuclei in the 
white substance of Schwann, disappearance of the axis-cylinder and slight 
fatty degeneration of the walls of the capillaries (Dejerine). 

Dejerine in the microscopic examination of five cases of paralysis dis- 
covered anatomical alterations in the gray substance of the spinal cord, the 
white substance being intact. He observed in the gray substance cells 
atrophied or in process of atrophy, with the disappearance of their prolonga- 
tions, so that healthy cells were comparatively infrequent. The cells seemed 
to have undergone the change which occurs in acute or subacute myelitis. 
The vessels in the gray substance were dilated and flexuose. They were in 
a state of hypera^mia or congestion, and at points small intestinal hemor- 
rhages had occurred. Around the central canal and in the commissures the 
nuclei were increased. The white substance of the spinal cord presented the 
normal appearance. These anatomical changes in the cord apparently resulted 
from a myelitis. The spinal nerves whose roots originated in the diseased 
gray matter of the cord were found to have undergone a similar change in 
their peripheral distribution. Therefore in the five cases in which such 
minute examinations of the nervous system were made the lesions in the 
cord and the nerves were similar. 

In 1883, Dr. E. Hyla Glreves of Liverpool, pathologist to the Royal 
Infirmary, obtained permission to examine the spinal cord in a child of 
three years who had died of sudden heart-failure after having suff'ered from 
an aggravated form of multiple diphtheritic paralysis. She had had anaes- 
thesia of the fauces and all her extremities, liquid food regurgitated through 
her nostrils and entered her larynx, she passed urine and feces in bed, she 
could not stand or sit without support, her head dropped helpless, her speech 
was indistinct, her tongue could not be protruded, her respiration w^as slow 
and shallow, her pulse 50 per minute and feeble, and she was nourished by 
enemata of pancreatized milk. The paralysis increased so that, the diaphragm 
alone acted in respiration, the pulse became slower, irregular, and more feeble, 
and death occurred suddenly. At the autopsy, which was limited to the 
spinal cord, the veins of the lower part of the cord were much congested ; 
the white substance of the cord presented the normal appearance to the 
naked eye, but the gray matter of the lumbar and lower dorsal regions was 



PARALYSIS. "409 

extensively softened, and in the left half of the cord diffluent, so as to flow 
from the section, leaving a cavity. Higher up in the cord the gray sub- 
stance was hypergemic, but not diffluent. The diffluent gray matter was 
unsuitable for microscopic examination, but other portions of the cord were 
examined, with the following result : Many ganglion-cells of the anterior 
cornua were destroyed or in the state of " cloudy swelling ;" others had lost 
their processes and were reduced in size ; increase in the number of nuclei in 
the neuroglia throughout the cord ; gray substance in the right half of the 
cord in an early stage of softening ; in the dorsal and cervical regions every- 
where the ganglion-cells were in a state of " cloudy swelling." No appre- 
ciable change in the white matter of the cord. It is evident that this was 
an extreme and rare case of degenerative change in the cord, and one in 
which the paraplegia, had the patient lived, would have been permanent, for 
the diffluent gray matter in the cord could not have been restored to its nor- 
mal integrity. It was not, therefore, an ordinary case, inasmuch as the 
paralyzed muscles, as a rule, recover their function in those who survive. 

Such is a summary of the lesions, peripheral and central, in the nervous 
system which have been discovered in fatal cases of diphtheritic paralysis. 
We have presented the facts upon which the theory of the cause and nature 
of the disease must be based. Are we able to present a theory which will 
hold good in regard to cardiac paralysis characterized by sudden heart-failure, 
to pulmonary paralysis characterized by superficial or embarrassed respiration, 
to palatal and multiple paralyses with their many inconveniences, and to the 
loss of the tendon reflexes ? 

Must we, with Trousseau, rest satisfied with the belief that the manner 
in which diphtheria produces paralysis is beyond our comprehension and will 
probably never be known ? Dr. Abram Jacobi, seeing the inadequacy of the 
various theories to explain all cases or forms of diphtheritic paralysis, wrote 
in 1880 as follows in his treatise on diphtheria : " It may be positively asserted 
that diphtheritic paralysis does not in every case depend on one and the same 
cause." 

The theory which is most strongly advocated at the present time, and 
which appears to be accepted by a large proportion of the specialists in 
nervous diseases under the lead of Charcot, is, as we have stated above, that 
diphtheritic paralysis results from a peripheral neuritis. Others, observing 
central lesions in the nervous system, have naturally inferred that they have 
an important share in the production of the paralysis. It is very important 
that the practitioner when confronted by this grave malady should have a 
clear conception of its cause and nature, that he may be better able to apply 
the appropriate remedies. We will, therefore, examine with the light obtained 
from clinical experience the prevailing theory that diphtheritic paralysis 
results from anatomical changes, peripheral or central, or both, in the nervous 
system. Is this theory adequate to explain the paralj-sis as it commonly 
occurs? We will give a brief summary of the objections to it, at the risk 
of repeating what we have already stated : 

1. Cases occur in which carefully-conducted microscopic examinations 
reveal an apparently normal state of the nerve supplying the paralyzed part 
and also of the nervous centre from which this nerve originates. 

Thus, in the three cases of typical cardiac paralysis described above 
occurring in the practice of Cadet de Gassicourt, the pneumogastric and its 
branches examined in one case appeared normal, and no lesion sufficient to 
cause paralysis was found in a careful examination of the medulla oblongata, 
the central organ of innervation of the heart. 

2. Palatal paralysis sometimes occurs as early as the second or third day 
of diphtheria, and loss of the tendon reflexes as early as the first day. Can 



410 DIPHTHERIA. 

we believe that a peripheral neuritis or anatomical changes in the cerebro- 
spinal axis have occurred at so early a date, so as to cause the paralysis ? 

3. In its commencement diphtheritic paralysis often exhibits what Trous- 
seau designates mutability. It suddenly shifts from one group of muscles 
to another. Muscles paralyzed on one day have their normal action on the 
following day, while other muscles are attacked, and on the third day the 
group of muscles first attacked are perhaps again -paralj^zed. This mutability 
of the paralysis, this sudden shifting from one group of muscles to another, 
militates strongly against the theory that the cause of the paralysis is a 
structural change in the nervous system, whether cerebral or peripheral. It 
would seem impossible that there should be a sudden recovery from the par- 
alysis, and then on the following day a recurrence of it, if it resulted from 
degenerative changes, either central or peripheral, occurring in the nervous 
system. These lesions do not undergo such sudden fluctuations, such muta- 
bility, as we observe in the paralysis, A persistent cause should produce a 
persistent and continuous effect. 

4. Several, if not all, of the microscopists who discover degenerative 
changes in the peripheral nerves which supply paralyzed muscles state that 
some nerve-fibres have undergone complete or nearly complete degeneration, 
others partial degeneration, and others still seem to be intact. Would com- 
plete paralysis result from such a state of the peripheral nerves ? Would, 
for instance, the velum palati, as we observe it, be motionless like a curtain, 
not exhibiting the least sensitiveness when pricked by the point of a pin or 
other instrument, if the sole cause of the paralysis were degenerative changes 
in the nerves? Would not the nerve-fibres which are still intact be sufficient 
to produce some motion ? May we not, in at least some instances, regard the 
paralysis as the cause of the degeneration in the nerves? — for it is a well- 
known pathological fact that if a muscle be paralyzed — as, for instance, from 
a central cause — the nerves supplying it usually undergo more or less degen- 
erative change. 

5. A clinical fact antagonistic to the theory that lesions in the cerebro- 
spinal axis cause the paralysis has been alluded to both by Dr. A. Suss and 
Dr. W^. H. Thomson in their interesting and instructive papers. It is that 
diphtheritic paralysis, motor and sensory, is sometimes limited to the muscles 
supplied by a single branch of a nerve, while the other branches have their 
normal function. This fact is, of course, not antagonistic to the theory that 
peripheral nerve-lesions cause the paralysis, but it affords a strong, if not 
conclusive, argument against the theory that central lesions are the cause. 

Such are the clinical facts which militate against the theory that inflam- 
matory or degenerative changes in the nervous system are the primary and 
sole cause of diphtheritic paralysis. We have stated above that the theory 
relating to the causation of diphtheria, which is now gaining acceptance in 
both continents with pathologists and specialists in diseases of children, is 
that the specific microbe of diphtheria acts locally upon the surface, and 
systemic infection occurs from ptomaines produced by microbic action, which, 
entering the lymphatics and blood-vessels, are carried to the interior of the 
body and exert their action upon the blood and the tissues. If this theory 
be true, the symptoms which indicate systemic infection are referable to the 
ptomaines. Dr. Thomson in his paper already alluded to writes as follows : 
" It is quite conceivable that a ptomaine may follow upon the changes which 
the diphtheritic process sets up in the organism, and thus produce all its 
characteristic symptoms. The special tendency of diphtheritic inflammation 
to cause necrotic and gangrenous lesions lends further support to this sur- 
mise." 

The ptomaines spring into existence suddenly and unexpectedly under 



PRO GX OS IS. 411 

favoring conditions, as we see in the case of the cheese or the milk ptomaine, 
the tyrotoxicon ; and it is not improbable that chemistry brought to the aid 
of microscopy will yet reveal the fact that the common cause of diphtheritic 
paralysis is a ptomaine or chemical agent produced by microbic action. If 
the cause be a ptomaine, it probably acts in a measure like the poison of the 
€el in the case alluded to by Trousseau, or like curare. Clinical facts appear 
to harmonize best with the theory that this is the common cause of the paral- 
ysis, especially in those cases in which it occurs early, and the use of the 
paralyzed muscles is soon regained. But it would be idle to argue that the 
marked degenerative central and peripheral lesions which are frequently pres- 
ent in the nervous system, in those who have died of diphtheritic paralysis, 
do not prolong and intensify the paralysis, and perhaps are sometimes the 
primary cause of it. 

Prognosis. — The prognosis of diphtheria, like that of scarlet fever, varies 
greatly in different cases according to its type. In some epidemics a large 
proportion of the cases are mild and recovery occurs with simple treatment. 
Between the mild and the most severe cases, attended by profound blood- 
poisoning, there is every grade of severity. Cases that are apparently mild 
in the beginning and seem likely to recover with simple measures sometimes 
become severe, dangerous, and even fatal. On the other hand, cases that set 
in with severity may become modified and end favorably with simple treat- 
ment. So variable is the type of diphtheria that in certain epidemics or 
localities a large proportion recover, as many even as 90 or 95 per cent., 
while in other epidemics or localities the proportion that perish is much 
larger. 

The prognosis is usually favorable when the inflamed surface and pseudo- 
membrane are of little extent, the fever and swelling moderate, and the neigh- 
boring l3^mphatic glands and underlying connective tissue but little involved. 
In many such cases, as we have seen from tlie description given above, the 
patient remains in good general health or feels but slightly indisposed. On 
the other hand, if the inflamed surface be extensive, the pseudo-niembrane 
deep-seated and exhaling an ofl'ensive odor, while the adjacent lymphatic 
glands are markedly swollen, the patient will probably perish. Nasal diph- 
theria, which is commonly present in severe cases, and which produces an 
oftensive, irritating, and highly infectious discharge, always involves great 
danger. It is likely to give rise to systemic infection, since the submucous 
connective tissue of the nostrils contains numerous lymphatics, which take 
up the poisonous products and convey them to every ]~»art of the system. If, 
while the local disease is severe and extensive, the breath and exhalations 
become ofl'ensive and the countenance and surface generally begin to have a 
dusky, pallid hue, profound blood-poisoning has occurred and the patient will 
probably die. 

Physicians of experience are guarded in the expression of a favorable 
prognosis in diphtheria, since there is no other disease in which the prognostic 
signs on which a favorable prediction is based are so likely to be fallacious. 
We hear much in medical circles of the deceptive character of diphtheria. 
Error in expressing a favorable prognosis, of which even physicians of ample 
experience complain, is largely due to the fact that diphtheria terminates 
fatally in several difierent ways. Death may occur from — 

1. Diphtheritic blood-poisoning — systemic infection by the specific prin- 
ciple, whether acting directly or through the agency of ptomaines which it 
produces. 

2. Septic blood-poisoning, produced by absorption from the under sur- 
face of the decomposing pseudo-membrane or from gangrenous tissues. 



412 DIPHTHERIA. 

But our knowledge is not sufficiently advanced to enable us to discrim- 
inate between the constitutional effects of ordinary sepsis and those pro- 
duced by the agency of the diphtheritic poison. Septic infection is obvi- 
ously most likely to occur in those cases in which the pseudo-membrane is 
extensive, deeply imbedded, and its- decomposition attended by an offensive 
effluvium. Cervical cellulitis and adenitis, which cause considerable swelling 
of the neck, often occur from septic absorption from the faucial surface, the 
septic matter being conveyed by the lymphatic vessels to the adjacent glands 
and causing inflammation of the glands and surrounding connective tissue. 
Considerable tumefaction of the neck therefore seldom occurs in diphtheria 
without manifest symptoms of toxaemia, and it is to be regarded as a sign of 
its presence. 

3. Diphtheritic croup or pseudo-membranous laryngo-tracheitis, a most 
important disease, and fully treated of in the proper place. 

4. Urgemia or diphtheritic nephritis, also one of the most important of 
the local maladies pertaining to diphtheria, and produced by the action of 
the diphtheritic poison. 

5. Sudden heart-failure. The action of the heart may be feeble from 
granulo-fatty degeneration of the muscular fibres or from aneemia or general 
weakness ; but sudden and unexpected death from heart-failure is commonly, 
as we have seen, due to paralysis of this organ. 

6. Suddenly-developed passive congestion and oedema of the lungs, prob- 
ably due to feebleness of the heart's action or to paralysis of the respiratory 
muscles. Death sometimes occurs, apparently from this cause, during the 
period of supposed convalescence and when the visits of the physician have 
been discontinued. Thus, in a case in my practice symptoms of oedema pul- 
monum (abundant moist rales in both sides of the chest and embarrassed 
respiration) suddenly occurred nearly one month after the disappearance of 
the faucial pseudo-membrane and inflammation. The urine, which had con- 
tained considerable albumen during the active period of the malady, had for 
some time shown no trace or but slight trace of this principle by the proper 
tests. By active stimulation these symptoms entirely disappeared in a few 
hours, and the heart's action seemed normal, except that it was a little Weak- 
ened. On the following day the symptoms reappeared, and death occurred 
before I was able to reach the house. 

That physician is obviously least likely to err in prognosis who recognizes 
the fact that patients are liable to perish in any of these different ways, and 
carefully examines in reference to all the conditions which involve danger. 
Many physicians, as I have had the opportunity to observe, are remiss in not 
examining more frequently the urine of diphtheritic patients ; for there is 
often a large amount of albumen with granular casts in the urine in diph- 
theria, indicating a poisonous quantity of urea in the blood, and yet the 
appearance of the urine to the naked eye is normal. 

Among the symptoms which render the prognosis unfavorable are repug- 
nance to food, vomiting, pallor of countenance, and general anaemia, with 
progressive weakness and emaciation, indicating blood-poisoning ; a large 
amount of albumen, with casts, in the urine, showing urasmia, to which the 
irritability of the stomach is often due ; an abundant irrritating discharge of 
muco-pus from the nostrils or occlusion of them by membranous exudation 
or inflammatory thickening, showing that the Schneiderian membrane is 
seriously involved ; hemorrhage from the nostrils, buccal cavity, or fauces, 
showing an altered state of the blood or of the walls of the capillaries, or 
plugging of the capillaries by masses of microbes or leucocytes. Diphtheritic 
laryngo-tracheitis, or pseudo-membranous croup, largely increases the aggre- 
gate of deaths from diphtheria, whether it be treated by improved inhalations^ 



PREVENTIVE TREATMENT. 413 

intubation, or tracheotomy. Some of the above symptoms have been present 
in most of the fatal cases which I have observed. On the other hand, the 
prospect of recovery improves in proportion to their absence. 

Preventive Treatment. — Diphtheria is so highly contagious, and when 
epidemic is so likely to spread from one household to another, and its severe 
forms are fatal in so large a proportion of cases, that preventive measures are 
of the greatest importance. The area of contagiousness of diphtheria is small. 
Dr. Lancry cites cases to show that it is limited to a few feet. Dumez also 
relates an instance showing that the contagious area is of small extent. In 
a school the boys and girls in the same hall were separated by an open space 
a few yards wide. Diphtheria prevailed among the girls, but did not affect 
the boys. In this respect, as in so many others, diphtheria resembles scarlet 
fever, and is unlike pertussis and measles. 

The most efficient method of preventing diphtheria is the isolation and 
disinfection of patients, the prompt and thorough disinfection of the apart- 
ments in which patients have been treated and of the bedding and furniture 
in these apartments, and the exclusion or prevention of all noxious gases, 
especially those ascending from the sewers and from filthy accumulations of 
all kinds. 

Dr. H. B. Baker of Michigan has published statistics showing that in 102 
outbreaks of diphtheria the average number of cases where disinfection and 
isolation, one or both, were neglected was 16, and the average deaths 3.26, 
while in 116 outbreaks in which isolation and disinfection were enforced the 
average number of cases per outbreak was 2.86, and the average deaths .QQ. 
Therefore these precautionary measures prevented 13 cases and 2.57 deaths 
for each outbreak ; in the total, 1545 cases and 298 deaths. These statistics 
relate to only one year.^ 

It is obvious that, in order to prevent the spread of diphtheria, wherever 
a case has occurred prompt and efficient personal and domiciliary disinfection 
should be practised so far as the condition of the patient will allow. But 
there is reason to think that disinfection as commonly practised is inadequate. 
In the winter of 1887-88 and the following spring an epidemic of diphtheria 
occurred in the New York Infant Asylum, and it extended to the maternity 
ward. In this ward 5 of the new-born infants contracted diphtheria, and 2 
of these 5 had at the same time umbilical phlegmons in addition to the usual 
diphtheritic exudate upon the fauces. It was evident from the occurrence 
of these cases that the maternity ward was infected to such a degree that 
subsequent patients could not be safely admitted without its thorough disin- 
fection. The ward was therefore vacated, the windows, doors, and crevices 
closed, and forty pounds of sulphur, or two pounds to the hundred cubic feet 
of air, were burnt until they were consumed. After some hours the windows 
and doors were opened, and Drs. Prudden and Cheesemen immediately raised 
a dust from the floor and bedding and allowed it to settle in culture-media. 
All other sources of infection were excluded from the media. The cultures 
produced so large a number of microbes that they overlay each other ; but 
the observers were able to distinguish the streptococcus pyogenes in the 
media, identical in form and appearance with the streptococcus which they had 
previously discovered in the umbilical phlegmon. Although more sulphur 
was employed than is recommended by the Ne'w York Health Board, and 
employed in the manner recommended by this board, it was inadequate to 
destroy the microbes. It was evident that some more efficient mode of domi- 
ciliary disinfection was required. 

Since the ordinary mode of disinfection was apparently futile in the 
maternity ward, it seemed to me advisable to obtain the views of so eminent 
^ American Lancet. (vSee Ann. Univ. Med. Sci., 1888.) 



414 DIPHTHERIA. 

an authority as Dr. E. R. Squibb of Brooklyn ; and he has kindly favored 
me with the following note : 

" Within the past ten years the efficacy of sulphur-fumigation against 
infectious material has been repeatedly denied and reaffirmed upon very good 
authority, and observations, apparently made with accuracy and care, have 
been reported from time to time to prove both sides of the question ; so that 
all that can now be said is that burning sulphur is of doubtful efficacy, with 
the weight of the highest authorities in bacteriology against it. But to this it 
must be added that it is still largely used by very intelligent bodies in large 
institutions, boards of health, etc., where it would not be likely long to main- 
tain an unearned confidence. 

" How often the fumes are applied dry and how often moist no one can 
tell from the current record ; and how many of the failures of the dry 
gas would be successes in the presence of moisture there is no means of 
knowing. 

" Formerly, when sulphur was burned in closed chambers as a disinfectant, 
the surfaces were all wetted, and the pot of burning sulphur was set in water 
or wet sand, that the heat might evaporate off a constant supply of watery 
vapor. 

" These conditions are now frequently, if not generally, neglected ; and 
where this is the case failure, on principle, should be the rule. 

" Nearly all, if not all, chemical disinfectants are in a state of tension, 
ready to change on coming in contact with the matter to which they are 
applicable; and these changes are either by oxidation or deoxidation, and 
the moment of greatest power or activity is the moment of change, when 
they by reacting on infectious matter pass from a state of tension to a state 
of rest under new relations. The agency through which these changes 
almost universally become operative is the vapor of water. 

" When sulphur is burned in a close chamber the dioxide is formed by 
condensing two molecules of oxygen from the air upon each molecule of the 
sulphur, and a heavy gas is the result, which tends to settle at the bottom of 
the chamber and to run out through the lower cracks. Any moisture present 
is at once seized by this rather inactive anhydride, first forming sulphurous 
acid, and then, by oxidation from the air, sulphuric acid. The dry gas, or 
anhydride, not only seizes with avidity all watery vapor in the air, but also 
the water held in the surfaces of all bodies with which it comes in contact, 
and in the presence of this moisture only is it ready for further oxidation. 
Then it is by this oxidation that it deoxidizes the matters with which it is in 
moist contact, filling the surfaces of these matters first with sulphurous acid, 
then, by the change, with sulphuric acid ; and it is during these changes 
that its power is exerted. 

" If there be no moisture supplied to the burning sulphur, that which 
was present in the air and the surfaces of the chamber is soon used up, and 
the dry gas remains indefinitely in a comparatively inactive, ineffective con- 
dition. The dry passive anhydride would necessarily destroy all organisms 
which breathed in any degree, because breathing-surfaces are moist. But 
in embryonic life protected by shell, as in seed, if the shell be dry the gas 
would be impotent. Many bacteriologists have admitted that burning sul- 
phur would kill bacteria, but not germs." 

It seems probable that the apparently negative effect of burning sulphur 
for the purpose of destroying the microbes in the maternity ward, as stated 
above, was due to the absence of moisture, for it was burnt dry. The above 
note from Dr. Squibb conveys very important information. If the facts as 
stated by him were more generally known and acted on by health boards 
and by physicians in family practice, the results of domiciliary disinfection 



PHEVEXTIVE TEE AT ME XT. 415 

would probably be better. It is so important that the specific principle of 
diphtheria should be destroyed wherever this disease appears, in order to pre- 
vent its propagation, that any safe measures which will aid in producing this 
result should be employed with or without the sulphur fumigation. To 
accomplish this purpose, Dr. Llewellyn Eliot recommends during the con- 
tinuance of a case the constant evaporation of turpentine over a water-bath, 
so that the vapor fills the room. In every instance in which he has used the 
turpentine no second case of the disease has occurred.^ I have stated, in my 
remarks on the prophylaxis of scarlet fever, that I have employed the follow- 
ing prescription for the purpose of disinfection during my attendance on cases 
of scarlet fever and diphtheria, with apparently so good a result that I am 
encouraged to continue its use : 

R. Acidi carbolici, .^j ; 

01. eucalypti, 5J ; 

Spts. terebinth., . 5viij. Misce. 

Add two tablespoonfuls to one quart of water in a pan with broad surface, 
and maintain a constant state of ebullition or simmering in the room occupied 
by the patient. This disinfecting vapor was employed in the quarantine wards 
of the Infant Asylum, in which diphtheritic patients were treated, and to a 
certain extent in the other wards, and no subsequent cases have occurred. 

In Bellevue Hospital, where pyaemia had been prevalent. Prof. R. Ogden 
Doremus employed chlorine gas mingled with steam to secure disinfection, in 
the following manner : Strips of paper having been pasted over the crevices 
around the doors and windows, equal parts of common salt and black oxide 
of manganese (about two hundred pounds) were placed in troughs formed 
of sheet lead, the edges being turned up to make receptacles. A carboy of 
sulphuric acid was emptied into small basins and other vessels and placed 
beside the troughs. The floors were moistened with water, and abundant 
steam was allowed to escape from the heaters into the ward. With the aid 
of assistants the sulphuric acid was quickly poured upon the mixture in the 
troughs and the room hastily vacated, the door being nailed up to prevent 
accidental entrance, for the large quantities of chlorine evolved would have 
been fatal. The following day the windows were opened from without, and 
after ventilation the contents of the troughs were stirred and sulphuric acid 
added as before. In the ward most infected this process was repeated once,, 
fresh salt and manganese being used. No further cases of pyaemia occurred 
in these wards. Even with the employment of a disinfectant vapor, the 
infected room or ward should not, in my opinion, be reopened until it has 
been disinfected in the manner recommended by Prof. Prudden. It is to rub 
the ceiling and walls with slices of fresh bread, and then apply to ceiling, 
walls, and floor a strong disinfectant solution, as of corrosive sublimate. 

In order to prevent as far as possible the spread of diphtheria, stringent 
measures should be taken to prevent propagation of the disease by walking 
cases, by children mildly aff"ected who are allowed to attend school and ride 
in public conveyances. I have in a number of instances seen children with 
diphtheria sitting with other children in the clinics at Bellevue. Recently I 
saw in consultation a child with fatal diphtheria, which apparently was con- 
tracted in the street by embracing a playmate who had been allowed to go 
out for the first time after an attack of the disease. In another instance a 
child went with its parent to a Sunday mission-school in one of the tenement- 
house sections of New York. Four or five days subsequently it had diph- 
theria, which was communicated to other children of the family, and one of 

1 Medical Bulletin. 



416 DIPHTHERIA. 

them died. The philanthropic endeavor to benefit the poor children of New 
York by conveying them to rural localities in midsummer has, it is said, 
resulted in the occurrence of diphtheria in farming sections where it was 
previously unknown. I have now under treatment a family with diphthe- 
ria, and the child first attacked states that a schoolmate sitting near her in 
the school complained of sore throat a few days previously. Certainly the 
safety of the public requires that all children with sore throats should be 
excluded from the schools whenever diphtheria is prevalent, and it should 
be the duty of teachers, acting under the direction of health boards, to see 
that this is done. 

In a paper relating to the therapeutics of diphtheria, read before the 
Philadelphia County Medical Society, May 23, 1888, and printed in its 
Transactions, Dr. A. Jacobi remarks that the well children in a family where 
diphtheria is occurring should not go to church or school, and that schools 
should be closed during an epidemic of diphtheria, or, if not closed, that 
teachers should every morning inspect the throats of the pupils and send 
home those with sore throats. Pie recommends also the disinfection of 
coaches and railroad-cars at regular intervals during an epidemic. He also 
states that a patient recovering from diphtheria may contract it anew from 
the curtains, carpets, and furniture which he has infected during his sickness, 
so as to have a renewal of the disease. He has seen patients die from these 
renewals, and has seen other patients improve immediately when removed to 
other apartments. He also states that an irritated surface is more likely to 
contract diphtheria than one that is healthy, and therefore buccal, faucial, 
and nasal catarrhs should be promptly treated, the cure of these diminishing 
the liability to diphtheria. Chronic nasal catarrh, he says, should be treated 
with two or three daily injections of a solution of salt (1 to 130), to which 
a 1 per cent, solution of alum may be profitably added, and the same may 
be gargled in the treatment of faucial catarrh. A nasal spray of nitrate of 
silver (1 to 500 or 1 to 1000) also hastens the cure. The inflamed buccal 
surface should be treated by the potassium chlorate or sodium chlorate. 
Enlarged tonsils, which may harbor the diphtheritic virus, should be reduced 
by the galvano-cautery, and enlarged cervical glands should also be treated 
as a preventive measure. Yery similar views were expressed in a paper 
read before the New York Academy of Medicine in January, 1888, by Dr. 
A. Caille, who believes that he has prevented the recurrence of diphtheria in 
those who have sufi"ered repeated attacks of it, by prolonged daily antiseptic 
treatment of their exposed surfaces, which harbored the poison or constituted 
a nidus favorable for its lodgment and propagation. Similar views were 
expressed in a paper read before the American Pediatric Society in June, 
1890, by Dr. Caille, who insists on the daily inspection of the throats of 
scholars whenever diphtheria is prevailing, and the exclusion from the schools 
of those who have sore throats. 

Treatment. — Although diphtheria' has been one of the most common of 
the severe infectious maladies in Europe and America during the last thirty 
years, physicians are far from agreeing in reference to the proper mode of 
treatment. The diversity of opinions in regard to the use of therapeutic 
agents is due in part to a variation in the type of the malady in different 
epidemics and localities, in part probably to the fact that other forms of 
inflammation of a severe type have been mistaken for the diphtheritic, but 
more to the fact that different theories have been held respecting the cause 
and nature of diphtheria. Hence one physician recommends with confidence, 
as eminently successful in his hands, a medicine or mode of treatment of 
which another speaks disparagingly. 

The germ theory, as described in the foregoing pages, according to which 



TREATMEXT. 417 

diphtheria is produced by a micro-organism, has had a marked influence upon 
the mode of treatment. The question has been much discussed whether 
diphtheria is primaril}^ a constitutional or a local malady. Acceptance of 
the germ theory does not require us to believe that diphtheria is primarily 
local, for the specific microbe might enter and infect the blood through the 
lungs before any symptom occurred, and, as we have stated elsewhere, the 
long incubative period of six or seven days in certain cases harmonizes with 
the theory of a primary blood-disease, rather than with the theory that diph- 
theria is in the beginning strictly local, its seat being upon one of the exposed 
surfaces where the microbe has effected a lodgment. But the latter theory 
is, as we have seen, more generally accepted, and certain facts lend strong 
support to it. But if diphtheria is primarily local, there can be no doubt 
that, as in the vaccine disease, the system becomes quickly infected in cases 
of ordinary severity, so that successful treatment requires the use of both 
constitutional and local remedies. Acceptance of the germ theory evidently 
leads to the employment of germicide remedies, the so-called antiseptics or 
antiferments, externally and internally, in order to destro}^ the specific prin- 
ciple of the disease. Hence, in proportion as this doctrine was accepted, 
carbolic acid, the chlorine preparations, bromine, the sulphites, salicylic acid, 
and the most prompt and efficient agent of this class, corrosive sublimate, 
came into use. 

Hygienic Treatment. — The patient should be placed in an airy room, and 
his evacuations should be promptly disinfected by chlorine, carbolic acid, or 
other disinfectant, and removed from the room. Purity of the air in the 
apartment is required ; but in the ventilation draughts of air through the 
room should be avoided, on account of the liability to diphtheritic croup, 
which produces about one-third of the deaths from diphtheria. 31. Jules 
Simon recommends that the windows of the sick-room be constantly closed, 
and that ventilation be obtained through the open window of the adjoining 
apartment. In bathing the patient care must be^ taken that he be not chilled. 
Bathing should be performed expeditiously in a warm room, with perhaps 
some increase of the stimulants administered. The patient should be con- 
stantly in bed, and the temperature of the apartment should be from 70° to 
75° F. A uniform temperature of the apartment at about 73° F. is safest. 

All physicians of experience recognize the importance of the use of the 
most nutritious and easily-digested food and the preservation of the appe- 
tite, for diphtheria produces rapid destruction of the red corpuscles and loss 
of flesh and strength, and it may soon produce a state of dangerous weak- 
ness. Beef tea or the expressed juice of meat, milk with farinaceous food, 
etc., should be administered every two or three hours or to the full extent 
without overtaxing digestion. I have sometimes employed the pepsin prepa- 
rations before each feeding, with apparently good results, as in the following 
formula : 

R- Pepsini purl, in lamellis, 3j ; 

Acidi muriat. dilut., .!^ij ; 

Glycerinfe, ,^j ; 

Aquse purse, ^iv. Misce. 
Dose : One teaspoonfid before each feeding. 

In cases of feeble digestion the predigested foods are often very useful, 
as the beef peptonoids of Reed and Carnrick, the sarco-peptones of the 
Rudisch Company, and peptonized milk. Failure of the appetite and refusal 
to take food are justly regarded as very unfavorable signs. Trousseau says : 
" Alimentation occupies the first place in the general treatment ; and I 
27 



418 DIPHTHERIA. 

have observed that the severer the attack the more imperative is the neces- 
sity to sustain the patients with^nourishing food. Loss of appetite — that is, 
disgust for every kind of food— is one of the most alarming prognostic signs. 
We must try to overcome the loathing of food by every possible means ; and 
to get nourishment taken I sometimes do not hesitate, in the case of children, 
to threaten punishment. When the patient retains his appetite for food, 
there is good hope of recovery."* Occasionally, when great dysphagia is 
present, whether from the severity of the pharyngitis or from palatal paral- 
ysis, it is necessary to resort to rectal alimentation. The rectum absorbs, 
but does not digest, and it is capable of absorbing peptonized food to such an 
extent that life may be sustained for an indefinite time without stomach 
digestion and solely by rectal alimentation. For the purpose of rectal ali- 
mentation I have usually employed peptonized milk containing in solution 
peptonized beef, as the sarco-peptones of the Rudisch Company. If this is 
administered through a No. 12 to No. 14 elastic catheter introduced far enough 
to reach the sigmoid flexure, and retained for half an hour by a compress 
pressed closely against the anus by the fingers, the result is, I think, better 
than when we depend, as Trousseau did, entirely on stomach digestion. One 
objection to the use of the brush, instead of spraying the fauces with the 
atomizer, is that it is more likely to cause vomiting, by which nutriment, 
that is so much required, is lost. In malignant cases of diphtheria, as in 
scarlet fever of a similar type, patients are sometimes allowed to slumber 
too long without nutriment. It is the slumber of toxaemia, and should be 
interrupted at stated times in order to give food and stimulants. 

Stimulants. — M. Sanne, in his treatise on diphtheria, says, " De tous les 
antiseptiques donnes a I'interieur, I'alcool est de beaucoup le plus sur. Plus 
Tinfection est prononcee, plus il faut insister sur les composes alcooliques." He 
states that Bricheteau reports the history of a patient who took daily during 
diphtheria a bottle and a half of the wine of Bordeaux, without the least 
symptom of intoxication or headache. A similar case was related to me in 
which nearly one and a half pints of brandy were given in twenty-four 
hours without any ill effect, and with an apparent good result on the general 
course of the disease. The same rule holds true in diphtheria as in other 
acute infectious maladies, that while mild cases do well without alcoholic 
stimulants, they are required in cases of a severe type, and should be admin- 
istered in large and frequent doses whenever pallor and loss of appetite or 
strength and flesh indicate danger from the diphtheritic or sepcic infection. 
It matters little how the stimulant is administered, whether milk punch or 
wine whey, provided that the proper quantity is employed. If given early 
and frequently in grave cases — as, for example, one teaspoonful every half 
hour of brandy or Bourbon whiskey — it does seem to have a tendency to 
render the disease more tractable ; but to be instrumental in saving life in 
malignant cases it must be given boldly from the start. If there be marked 
diphtheritic toxaemia when its use is commenced, it will not save life, but it 
may prolong it. Although the liberal employment of alcohol is apparently 
useful, it cannot be regarded as a specific. In the quarantine wards of the 
New York Foundling Asylum in May, 1878, were four children between the 
ages of three and five years who had been sick a few days with severe diph- 
theria, and it was evident at a glance that they must soon perish with the 
ordinary mild sustaining remedies. Quinine, iron, the most nutritious food, 
and a moderate amount of alcoholic stimulants were being given, and we 
determined to increase the Bourbon whiskey to a teaspoonful every twenty 
or thirty minutes day and night. Nevertheless, whatever the result might 
have been with the earlier commencement of this treatment, the blood-poi- 

•^ American Lancet. 



TREATMENT. 419 

soning was now too profound, and one after the other died. That intoxica- 
tion is almost never produced in this disease by large and frequent doses of 
the alcoholic stimulant is probably in part due to its quick elimination from 
the system, but more to the nature of diphtheria. 

In fulfilling the indication of sustaining treatment the vegetable tonics 
have long been used, especially cinchona and its alkaloid principle, quinine. 
The compound tincture of cinchona and the fluid extract have been used and 
recommended by physicians of experience, but of vegetable agents quinine 
has been and is still more frequently prescribed than any other. But the 
doses employed vary greatly in size and frequency in the practice of differ- 
ent physicians. It is administered for its antipyretic effect in large doses, 
so that twenty or thirty grains are given daily, and in small doses, as one or 
two grains every fourth hour, for its tonic effect. That there is nothing 
antagonistic in the action of quinine to the diphtheritic virus, and that it is 
beneficial in the same way as in the other acute infectious diseases, and no fur- 
ther, is, I think, generally admitted by physicians. Large and frequent doses 
do not, apparently, produce any controlling action on the course of the disease 
or diminish the blood-poisoning. Cases might be cited in illustration. In 
the case of a child of four years with malignant diphtheria forty-eight grains 
administered daily had no appreciable effect in staying the fatal progress of 
the disease. 

Quinine in doses of three to five grains has been prescribed as an anti- 
pyretic in diphtheria, as also in the other infectious diseases ; but as an anti- 
pyretic it is not very efficient, and the temperature after the first two or three 
days in diphtheria is not often so elevated that an antipyretic is required. 
As a tonic in doses of one to two grains it is probably to a certain extent 
beneficial, and it has been highly recommended by good observers for its local 
action upon the fauces when used by insufflation. The late Prof. Rochester 
of Buffalo recommended and practised in the treatment of diphtheria the 
insufflation of sulphate of quinine, in powders of two grains, upon the faucial 
surface, every two hours. ^ It is not improbable that benefit may result from 
its local action, for used in this manner it is antiseptic. But the employment 
of this agent by insufflation is very unpleasant to the child, and is likely to 
be resisted. Given in solution in doses of two grains, as in the following 
formula, it produces some local action on the fauces if drinks be withheld 
subsequently for a few minutes, and at the same time some tonic effect prob- 
ably results from its use in this manner : 

B:. Qainise sulphat., ^ss; 

Syr. yerbte sant^ comp., ^ij. Misce. 

Give one teaspoonful every two to four hours to a child of five years. I 
have often prescribed quinine in this manner with apparent benefit in the 
treatment of diphtheria. 

Tinctura Ferri CKloridi. — All physicians who are familiar with diphtheria 
have noticed the pallor and loss of appetite, flesh, and strength which com- 
mence before the close of the first week in severe cases, and which are always 
unfavorable symptoms, indicating as they do rapid and progressive deteriora- 
tion of the blood. The use of iron is at once suggested as the proper medici- 
nal agent to arrest this blood-change, from its known effect in increasing the 
number of red blood-corpuscles and the amount of coloring matter in these 
corpuscles. By its effect on the red corpuscles, which are the carriers of 
oxygen, it increases the functional activity of organs and improves the gen- 
eral nutrition. The ferruginous preparations, therefore, hold an important 
■■- New York Medical Journal. 



420 DIPHTHERIA. 

place in the therapeutics of diphtheria. The one which has stood the test 
of experience and is now commonly employed is the tincture of the chloride 
of iron. It should be given in large and frequent doses, as five drops hourly 
to a child of three years. 

Ferguson^ regards the tincture of the chloride of iron as the most val- 
uable of all remedies for diphtheria. He examined the blood daily or every 
second day in twenty cases of diphtheria, and was astonished to observe how 
rapidly the red blood-corpuscles were reduced in number, those remaining 
presenting an unhealthy appearance. He believes that the iron partially 
arrests the blood-change. He administers as much as can be tolerated. To 
a child of ten years he gives hourly one teaspoonful of the following mix- 
ture in water: 

R. Tinct. ferri chloridi, ,^j ; 

Syr. simplic, ^iij. Misce. 

If the stomach do not tolerate this dose, half a teaspoonful is administered 
every half-hour. An infant of seven months, greatly prostrated, took every 
hour one teaspoonful of the following : 

R. Tinct. ferri chloridi, ^ij ; 

Syr. simplic, ^iv. Misce. 

A lady of twenty-two years, having an excessive formation of pseudo- 
membrane and a very fetid breath, took daily one and a half fluidounces 
of the iron for ten days. 

M. Jules Simon says:^ *' For internal treatment from three to six drops 
of the tincture of the chloride of iron should be given in a little water every 
two or three hours ; but it should not be given with milk or gum-water or 
from a metallic spoon, on account of the decomposition which occurs, which 
may produce digestive troubles." Dr. Whittier believes that this medicine, 
given so as to saturate the system, is the best that can be employed. In 
thirty-six consecutive cases in which the fauces were covered with the exu- 
date, all recovered under the use of the iron as the principal medicine.^ Dr. 
S. Baruch of New York prescribes hourly doses of this remedy in quantities 
varying from eight to twenty-five drops mixed with glycerin and water. 
Food and stimulants are administered before the iron, but not immediately 
afterward, so that the iron may have a local action upon the faucial surface.* 
Dr. Billington recommends hourly teaspoonful doses of the following mixture : 

R. Tinct. ferri chloridi, fjj ; 
Glyceriuse, 
Aquae, da. ^j. Misce. 

Prof. Joseph E. Winters says that he has given two drachms of the 
tincture of the chloride of iron every half hour for forty-eight hours, with 
manifest benefit, to a child of eight years.^ But it is only in the most severe 
or malignant form of the disease, the form described by Sanne as septic 
phlegmonous, that such large doses are proper or are required. In mild 
cases from three to five drops given hourly or oftener suffice. This is the 
dose recommended by Jules Simon of Paris. 

Several recent writers make the plausible statement that the indication 
of treatment by the iron is to saturate the system as soon as possible, employ- 

^ Canadian Practitioner. ^ Le Progres medical. 

3 Boston Medical and Surgical Journal. * New York Medical Record. 

^ Diphtheria and its Management, 1885. (See Ann. Univ. 3[ed. Sci., 1888.) 



TREATMENT. 421 

ing for this purpose as large and frequent doses as can be tolerated by the 
stomach. The tolerance of a drug depends largely on the manner in which 
it is employed. The best vehicle for the tincture of the chloride of iron is 
glycerin and water. It may be conveniently prescribed with two or three 
times its quantity of glycerin and a certain number of drops administered in 
water. The advice of Simon should be borne in mind, not to give it with 
gum-water nor with milk nor from a metallic spoon. 

That now, after nearly half a century of the constant use of iron in diph- 
theria in both hemispheres, there is an almost unanimous verdict in its favor, 
renders it probable that the few who have not observed its good effects have 
treated unusually bad cases or have given the medicine in small and inade- 
quate doses. We shall see that the opinions of physicians have not remained 
equally favorable in regard to the use of the agent with which the iron has 
been commonly combined, the potassium chlorate. 

Potasman Chlorate. — This agent produces a curative effect on buccal 
inflammations, and its beneficial action when employed for the various forms 
of stomatitis has led to its extensive use in pharyngitis. When taken inter- 
nally it is eliminated in part by the salivary glands, so that it continues to 
exert in part a local action on the surface of the mouth and fauces until it is 
entirely eliminated. This medicine, the potassium chlorate, has of late years 
become also a domestic remedy, but the laity should be cautioned in reference 
to its use. It is an irritant to the kidneys in large doses, producing intense 
inflammatory congestion of these organs and arresting their function. The 
melancholy fate of Dr. Fountaine oiP Davenport, Iowa, in 1861, whose life 
was sacrificed by an experimental dose of potassium chlorate, is remembered 
by the older physicians. Fountaine took half an ounce in a gobletful of 
warm water at eight A. M. Free diuresis occurred, which ceased at four 
p. M. Though fatigued and pallid, he ate a hearty supper. During the 
following night he was in collapse, with vomiting and purging and severe 
abdominal pain. Early in the following morning he voided two ounces of 
dark urine, after which no urinary secretions occurred. The choleraic symp- 
toms returned, with collapse, but he again rallied. He had vomiting and 
intense and constant abdominal pain durino' the subsequent six days, when 
death occurred. The total cessation of fecal and urinary evacuations for six 
days was a notable fact. At the autopsy the lesions of an intense and gen- 
eral gastro-intestinal inflammation were present, the mucous membrane hang- 
ing in shreds and patches ; the bladder was empty, and its mucous membrane 
presented a -similar appearance to that of the stomach and intestines. The 
condition of the kidneys is not stated, except that there was liquid resem- 
bling urine under the capsule of one kidney and crystals of the chlorate 
were in the pelves of the kidneys. A few years since, in my practice, a child 
of three years with active diphtheritic pharyngitis was allowed to quench its 
thirst by drinking water from a small pitcher in which three drachms of 
potassium chlorate had been dissolved, and which had been ordered as a 
gargle. In the morning I was summoned in haste, and found the surface of 
the patient cold and blue and pulse feeble. The urine was totally suppressed, 
and instead of it a few drops of blood passed from the urethra. Death 
occurred before night. 

Jules Sim on ^ says that potassium chlorate, acting wonderfully well in 
diseases of the mouth, produces no beneficial effect in diseases of the fauces, 
and it weakens the little patient when given in large doses. Dr. J. P. Esch 
says that he has observed that the potassium chlorate used internally in diph- 
theria almost invariably produces symptoms of nephritis. Ferguson- totally 
condemns its use in any dose or mode of administration in diphtheria. In 

^ Le Progres medical. ^ Canadian Practitioner. 



422 DIPHTHERIA. 

every case in which he employed it, if albuminuria were present it increased 
the amount of albumen. Yon Focke^ believes that any benefit which may 
be derived from the potassium chlorate in diphtheria results from the oxygen 
in it. To render the oxygen more efficient, he adds hydrochloric acid. He 
prepares a 2 per cent, solution of the chlorate, with a IJ per cent, solution 
of the acid, and administers a half-teaspoonful to two teaspoonfuls, according 
to the age, every one to two hours. All the benefit obtained from this mix- 
ture may be derived from a prescription long used and favorably known in 
New York, and probably more frequently written than any prescription 
for diphtheria. The tincture of iron in the mixture contains one minim of 
free muriatic acid in each drachm, but a small amount of this acid is added 
to the mixture in addition. The prescription, with some variations in its pro- 
portions in the practice of different physicians, is as follows : 

R. Tinct. ferri chloridi, 3ij~iij ; 

Potas. chlorat., gj ; 

Acidi muriat. dilut., gtt. x ; 

Syr. simplic, 3iv. Misce. 
Dose : One teaspoonful hourly or each second hour. 

After such an extensive use of potassium chlorate during nearly half a 
century its therapeutic uses should be clearly defined, and any ill effects 
which may result fully determined. From what is now known of its action, 
it would probably be better to abandon its use in diphtheria, since it is a 
remedy of doubtful efficacy for throat affections. If it be employed, it should 
certainly be administered in small doses sufficiently diluted. If it be pre- 
scribed, it should not, I think, be in larger quantity than half a drachm in 
twenty-four hours for a child of five years. 

The remedies mentioned above are those which have been most largely 
employed for internal medication by physicians of the present and the pre- 
ceding generations ; but the belief that diphtheria has a microbic origin, 
that the action of the microbes gives rise to poisonous ptomaines, and 
that the virulence of the disease is due to these organisms and chemical 
products, has daring the last few years brought into prominence the germi- 
cide and antiseptic treatment. The attempt is now made — and apparently 
with considerable success — to cure the patient by antagonizing and destroy- 
ing the cause of diphtheria. We look with interest and for enlightenment to 
the results of treatment by the antiseptics, and compare them with the results 
obtained by the use of tonics, stimulants, and alimentation, which have been 
heretofore employed. 

Among the most useful of the statistics bearing upon the action of germi- 
cide and antiseptic remedies in the treatment of diphtheria are the following, 
made by N. Lunin in the hospital of Oldenburg in 1882.'^ In this hospital 
296 children had diphtheria, and 164, or 55 per cent., died. The treatment 
by corrosive sublimate consisted in brushing the pharynx every two hours 
with a solution of 1 part to 1000, or in spraying by the irrigator of Rauch- 
fuss with a solution of 1 part to 5000. The patients subjected to this 
treatment numbered 57 : 43 of them had the fibrinous form of the dis- 
ease, and 14 the septic phlegmonous form ; 13 of each class died, or 45 
per cent, of the whole number. The tincture of chloride of iron Lunin 
employed in small doses, only one drop every quarter-hour, or two drops 
every half-hour, in 94 cases, 43 having the fibrinous form and 51 the sep- 
tic phlegmonous form. The total mortality was 56.3 per cent. Irrigation 
of the fauces was also employed in these cases with a 3 per cent, solu- 

'^Wien.med. Wochensckr. "^ Archivfdr Kinderheilk., 1886. 



TREATMENT. 



423 



tion of boric acid. Lunin made use of cliinoline in 28 cases — 19 of the 
fibrinous form and 9 of the septic phlegmonous form : 15 died, or 53 per 
cent. This agent was prescribed in a 5 per cent, solution, the medium being 
half water and half alcohol. Twenty-nine children were treated by resorcin, a 
solution of 10 per cent, being applied by the brush twice hourly, and irrigation 
with a 1 per cent, solution once hourly. 65 per cent. died. A solution of 
bromine and bromide of potassium was applied from one to three times hourly 
to the fauces in 33 patients, but 69.7 per cent. died. 

Finally, 23 infants were treated by turpentine, a tablespoonful twice daily, 
and in some of the cases an additional hourly dose during two or three days. 
The mortality was 43. -l per cent. In the fibrinous form the percentage of 
deaths from the different modes of treatment was as follows : 



Percentage. 

By turpentine . . . '. 8.30 

" resorcin 20.00 

" corrosive sublimate 30.20 



Percentage. 

By chinoline 31.60 

" tinct. ferri chloridi 32.60 

" bromine 46.70 



In the septic form the deaths were as follows 



Percentage. 

By tinct. ferri chloridi 76.5 

" turpentine 81 

" bromine 88.9 



Percentage. 

By resorcin 89.5 

" corrosive sublimate 92.9 

'' chinoline 100.0 



Therefore, according to Lunin's statistics, turpentine was the most useful 
agent in the fibrinous form of diphtheria, and the tincture of the chloride 
of iron in the septic phlegmonous form. 

Hydrargyri Chloridum Corrosivum (^Hydrargyripercliloriduin^ Br. Phar.). — 
The use of this agent in the treatment of diphtheria is based on the theory 
of the microbic origin of this disease. Corrosive sublimate is the most active 
and certain of the germicide agents employed in medicine, whether used 
locally or internally. It quickly destroys all micro-organisms with which 
it comes in contact, and in safe medicinal doses it is believed to penetrate all 
parts of the system. The employment of corrosive sublimate in the treat- 
ment of diphtheria is not new, since it appears that the late Dr. Tappan of 
Steuben ville, Ohio, prescribed it with apparent benefit in 1860-61 ; but it 
was seldom prescribed as a remedy in this disease until within the last four 
or five years. The establishment of the theory of the microbic origin of 
diphtheria, and a knowledge of the fact that the sublimate is the most 
efficient germicide, have made it the favorite remedy with many physicians. 
Of course its employment demands caution, and is justified only by the fact 
that the disease for which it is prescribed has hitherto been very fatal with 
other modes of treatment. Though this agent is now widely used for 
diphtheria, medical journals thus far contain very few reports of its 
supposed toxic or injurious action, while many physicians believe that it 
diminishes the virulence of diphtheria and increases the percentage of 
recoveries. 

In ordinary cases the following may perhaps be regarded as about the 
proper quantities which should be administered in divided doses in twenty- 
four hours : For a child of two years, gr. -J- (gr. ^-^ every two hours) ; for a 
child of four years, gr. \ (gr. J-g- every two hours) ; for a child of six years, 
gr. 1 (gr. gL- every two hours) ; and for a child of ten years, gr. ^ (gr. J^ 
every two hours). Thus, if we employ the vehicle which Dr. Tappan used 
a quarter of a century ago, the following prescription might be written for a 
child of six years : 



424 DIPHTHERIA. 

R. Hydrarg. chlor. corros., gr. j ; 

Alcoholi, ;5ij ; 

Elix. bismuthi et pepsinii, q. s. ad ^iv. Misce. 
Dose : One teaspoonful every two hours. 

According to the statement of physicians, considerably larger doses have 
been administered with safety and apparent .benefit, and in severe cases, 
attended by profound blood-poisoning, such as Lunin designates septic phleg- 
monous, certainly the maximum medicinal dose is required if we depend on 
the sublimate as the main remedy. Dr. Grant (Bey) administered to a child 
of four years one-half grain every half-hour till six doses were taken, and 
then hourly during the first day, every second hour on the second day, and 
on subsequent days at longer intervals. Dr. A. Jacobi states that an infant 
a year old may take one-half grain every day for many days in succession 
with very little, if any, intestinal disorder and with no stomatitis. Although 
certain children may tolerate doses so large as those recommended by Dr. 
Grant (Bey), safer doses are those which we have recommended above, and 
they seem to be sufficient for protracted use. Dr. P. Werner ^ recommends 
in the treatment of diphtheria the sublimate dissolved in distilled water, in 
half-hourly doses or at a little longer interval, so that the following quantities 
are taken in twenty-four hours : For an infant of one and a half years, 0.015 
(grain 0.231) of the sublimate in 120.0 (4 fl.oz.) of water ; for a child at the 
age of six to seven years, 0.3 in 180 (grain 0.45 to 6 oz.) of water. The 
quantity is to be given in divided doses in the twenty-four hours. At night, 
if the child sleep, the doses should be less frequent and proportionately 
larger than in the day-time. Dr. I. N. Love of St. Louis states that he has 
employed the sublimate in doses of one-one-hundredth to one-fiftieth grain 
every hour or second hour, according to the age, preceded by large draughts 
of water. Its action as thus used seemed to be both local and constitutional. 

Those who denounce the use of mercurials in diphtheria, like Jules 
Simon and one at least of our distinguished American writers — grouping 
together calomel, the oleate, the unguentum, the cyanide, the biniodide, and 
corrosive sublimate, condemning them in a body — on the ground that they 
enfeeble the system, do injustice to the therapeutic virtues of the sublimate. 
Medicines having the same base often differ widely in their action upon the 
system ; and it is the common and probably correct belief that the sublimate 
in safe medicinal doses does not enfeeble the system, but in some instances 
acts rather as a tonic. 

In my practice excellent results have apparently occurred from the local 
use of corrosive sublimate — its use by the atomizer. If the sublimate be 
administered internally at the same time, care must be taken not to employ 
too much. The solution which I have prescribed with the atomizer consists 
of two grains of the sublimate to one pint of water, and in spraying the 
fauces the bulb of the atomizer is compressed from three to five times. In 
ordinary cases the spray is used every second hour. Oatman of Nyack, 
New York, has lost but 1 patient in 23 by the following local treatment : 
Cotton is firmly wound around the end of a stick about the size of a lead- 
pencil, being drawn out as it is wound, and made to project beyond the end. 
This is dipped into a solution of the bichloride of mercury, two grains to the 
pint (1 to 3840), and passed into the throat until it touches the posterior 
wall of the pharynx. It is then instantly withdrawn and burnt. This 
treatment is repeated hourly with a new swab each time, until the inflam- 
mation begins to subside, which is usually in forty-eight hours. Jules 
Stiimf- treated 31 cases, with 2 deaths, by inhalation of the sublimate, 

^ St. Petersburg, med. Wochenschr., 1886. ^ Munch, mecl. Wochenschr. 



TREATMENT. 425 

using the apparatus of Richardson. For infants under the age of two years 
he employs 1 part to 4000 ; from five to six years, 1 part to 2000 ; for those 
over six years, 1 part to 1000. Dr. Thomas Welcher recommends in the 
treatment of diphtheria,^ used as a gargle or employed as a spray, a solution 
of corrosive sublimate of 1 to 1000. In most instances, when this local 
treatment had been employed a few times at intervals of one to two hours, 
the pharyngeal disease began to abate and the general condition improved. 
Dr. Welcher also employs small doses of the sublimate internally. It is 
evident from the experience of other physicians that when this agent is used 
as a spray in so strong a solution as 1 to 1000, it should be used with caution. 
Two or three compressions of the bulb will be suf&cient. Prof. A. Jacobi 
recommends for washing the nares a solution of corrosive sublimate of from 1 
part to 2000 to 1 part to 10,000, with or without 10 to 50 parts of table-salt 
or 60 to 300 parts of boracic acid. 

The medical journals during the last three or four years contain abundant 
testimony to the beneficial results of both the internal and the local use of 
corrosive sublimate in diphtheria. An important question evidently arises — 
to wit, how to use this active agent internally and locally at the same time 
without administering too large a quantity. Some physicians administer 
the amount that can safely be employed in twenty-four hours dissolved in 
water and in frequent doses (every hour or second hour), and if no drinks be 
given subsequently for a few minutes the local efi'ect upon the fauces is to a 
considerable extent obtained. Perhaps this is the safest and best mode of 
employing this very efl&cient and useful antiseptic agent in the treatment of 
diphtheria. 

Calomel. — Dr. Simon Baruch begins the treatment of all cases of diph- 
theria not attended by diarrhoea by a dose of four to eight grains of calomel, 
followed, if necessary, by a laxative.^ He cites the experience of Dr. 
Coester, who administered, in the preliminary treatment of diphtheria, 
calomel in 69 cases, and lost only 1. Prof. Simon of Paris in the treatment 
of diphtheria discards (1) blisters, which are always followed by the repro- 
duction of pseudo-memlDrane ; (2) bleeding and mercurials, which enfeeble 
the patient ; (3) preparations of opium, which produce rapid depression of 
the vital powers ; and (4) potassium chlorate in large doses. The reference 
of Simon to mercurials is probably more particularly to calomel.^ 

On the other hand. Dr. Greo. B. Fowler considers calomel the best remedy 
with which to combat diphtheria. When croupy symptoms supervene he 
increases the dose from gr. i to gr. ^J, or even 1 grain, every hour.* Dr. I. 
X. Love remarks that the most marked recent recommendation of the use of 
calomel in diphtheria is from the pen of Dr. William H. Daly, chairman of the 
Laryngological Section of the Ninth International Medical Congress.^ Dr. 
Daly's method is to administer the calomel two to five grains every one, two, 
or three hours until free catharsis follows, and then at longer intervals, but 
so that three or four daily evacuations are produced. The editor of the 
Therapeutic Gazette writes : " AVe have so frequently seen an apparently 
severe attack of diphtheria abruptly aborted in its inception under the 
influence of large doses of calomel that we can scarcely believe that the 
drug has no pronounced efi'ect. A grain of it should be put dry in the 
mouth of the child every hour or two until frequent, very loose, liquid 
evacuations are produced." 

In addition to those already mentioned, other physicians of ample expe- 
rience have recommended calomel in the treatment of diphtheria, some in 

' Deutsche med. Zeit. ^ New York Medical Record. 

^ Jour, de Med. de Paris. * New York Medical Record. 

^ Weekly Medical Revieic. 



426 DIPHTHERIA. 

laxative doses and only at the beginning of the attack, and others in doses 
of the fractional part of a grain every two to four hours during the sickness. 
The majority of physicians — very properly, in my opinion — discourage the 
employment of calomel in laxative doses, believing that it tends to weaken 
the patient and increase the anaemia, which in all cases of severe diphtheria 
soon becomes very manifest, whatever the treatment ; but a single laxative 
dose is perhaps sometimes useful. It may do good, as in other infectious 
diseases, to unload thepnmas viae, in the commencement of the attack, so that 
the remedies to be employed are more readily absorbed and without alteration 
by admixture with chemical products in the intestinal tract. What change 
calomel undergoes so that it can be absorbed has not been clearly ascertained. 

Turpentine. — This has been highly recommended recently by physicians 
of experience, when used locally as well as internally, for its prompt action 
in arresting the formation and extension of the pseudo-membrane and as an 
antidote to the diphtheritic virus. Dr. Rewentauer states that an infant of 
two years treated by other remedies began to have symptoms indicating inva- 
sion of the larynx on the fourth day. Tracheotomy was resolved upon, but 
previous trial was made of pure turpentine in a teaspoonful dose. The croup- 
iness ceased, other symptoms improved, and the patient recovered without 
tracheotomy.^ 

Delthil and, following him, Schenker employed a mixture of coal-tar and 
turpentine, which was burnt in the room occupied by the patient either con- 
stantly or several times through the day. Schenker's observations led him to 
believe that the benefit from this treatment occurred chiefly from the turpen- 
tine, and largely from its general effect on the system. He therefore decided 
to employ turpentine internally in doses of ten minims to one teaspoonful, 
one to three times daily, in milk, sugar-water, or gruel. At the same time he 
employed it as a spray. Alcoholic stimulation, cleanliness, and a diet of beef 
tea, milk, and egg were enjoined. Of '36 cases which Dr. Schenker treated 
by turpentine, 31 recovered. 

Rose of Hamburg employed turpentine in teaspoonful doses mixed with 
spirit of ether (ether one part, alcohol three parts) three times daily. A tea- 
spoonful of a 2 per cent, solution of salicylate of sodium was also given every 
two hours. Under this treatment the temperature and pulse diminished, other 
symptoms improved, and in 58 cases thus treated 95 per cent, recovered.^ 
Sigel also prescribed turpentine in teaspoonful doses in 47 cases, in 14 of which 
the question of tracheotomy arose. A manifest reduction of temperature 
followed the use of the turpentine. The percentage of deaths in all thus 
treated was 14.9, while of those treated by corrosive sublimate, salicylic acid, 
potassium chlorate, etc., 32.5 per cent. died. Dr. Llewellyn Eliot also reports 
good results from the vaporization of turpentine. 

The rece-nt recommendation of turpentine in the treatment of diphtheria 
by many physicians of large experience and sound judgment, among whom 
we may mention Drs. S. Baruch and A. Jacobi, has extended and established 
the use of this agent. Its supposed efficacy depends on the fact that it is 
antiseptic and germicidal, and that when vaporized and inhaled or taken by 
the stomach it penetrates all parts of the system. The descriptions long 
given in the text-books of the physiological action of turpentine have had 
the tendency to induce physicians to employ it in small doses. But I am not 
aware that any writer has recorded ill effects from the use of turpentine in 
diphtheria, although it has been employed by a considerable number of phy- 
sicians in the last year or two, and in quantities which exceed the medicinal 
doses mentioned in text-books. 

It is well known that the constitutional effects of the oleum terebin- 

^ Centralbl.f. klin. Med. ^ Therap. Monatschr. 



TREATMENT. 427 

thinae, even to impaired vision, strangury, and bloody urine, may be obtained 
by the prolonged inhalation of its vapor ; ^ and I have employed the vapor 
of the oil of turpentine during the last two or three years with such appa- 
rent good results that J. confidently recommend the mode of using turpentine 
as recommended in our remarks under the head of Prophylaxis. Turpentine 
will probably in the future be a very important remedy in the treatment of 
diphtheria, whether taken by the stomach or received as a spray. 

Pilocarjyme. — Certain physicians have recommended pilocarpine in the 
treatment of diphtheria, because it is supposed that the salivary and mucous 
secretions which it produces aid in throwing oflf the pseudo-membrane. Dr. 
Lax states that the 10 patients treated by him, some of them severely sick, all 
recovered.^ He employed the following prescription : 

R. Pilocarpini hydrochlorat., gr. ^^ to | ; 

Acidi hydrochlorici, gtt. ij-iij ; 

Pepsini, gr. x-xij ; 

Aquse destillat., gxviiss. Misce. 
Dose : A teaspoonful or tablespoonful in wine. 

Guttmann treated in a year and a half 81 cases by this remedy without 
a death. Gelsner and Delewsky also report good results. On the other 
hand, I have seen the most disastrous eifects from the use of pilocarpine in 
diphtheria, the secretions filling the bronchial tubes and being expectorated 
insufiiciently and with great difficulty. Death resulted. The symptoms 
which occurred were like those in extreme oedema of the lungs. I cannot 
therefore recommend its use. Its employment appears too hazardous, espe- 
cially in young and feeble children. 

Sodium Benzoate. — Dr. L N. Love recommends the sodium benzoate 
in five-, ten-, or fifteen-grain doses.^ He remarks that Salkowski in 1879 
noticed that this drug largely increased the secretions by the kidneys of nitrog- 
enous and sulphurous compounds, and concluded that it would aid in 
depurating the blood of noxious matters. Salkowski, Fleck, and Buckholtz 
ascertained that the benzoate arrested the growth of micro-organisms in 
putrid liquid, and Graham Brown that diphtheritic liquids became non- 
contagious by the addition of the benzoate. Helferich, Graham Brown, and 
Sanne, from experiments made on animals, consider the benzoate of sodium 
a specific against the virus of diphtheria.^ On the other hand, M. Dumas, 
surgeon to the Hopital de Cette, has not derived any marked benefit from its 
use, and Dr. A. Jacobi says that it does not deserve the eulogies bestowed 
upon it from theoretical reasonings.^ 

Such are the more important remedies, used internally, which have been 
up to the present time employed in the treatment of diphtheria. The num- 
ber, it is seen, is large, and most of them are no doubt useful in certain cases. 
Diphtheria, being a disease of variable type, must be treated according to the 
indications in each case. The internal remedies which in my opinion have 
been most useful, and which should be most frequently employed, are the 
tincture of the chloride of iron, quinine, corrosive sublimate, turpentine, and 
the alcoholic preparations. 

Among the other remedies which have been recommended by good 
observers, we may mention the following : Copaiba and cubebs are employed 
and recommended by distinguished French physicians. Jules Simon pre- 
scribes copaiba and cubebs for patients over the age of five or six years.® 

^ Stille and Maish. ^ Medical News. 

^ Weekly Medical Review. ' * La France mediccde. 

^ New York Medical Record. ^ Le Progres medical. 



428 DIPHTHERIA. 

Dr. I. H. Fruitnight lias employed the sodium hyposulphite in 8 cases, 
giving hourly drachm doses of the following: R. Sodii hyposulph., ^j ; Aquae, 
f|ij. The result was favorable. Illingworth^ recommends the biniodide of 
mercury. Dr. C B. Galentine recommends the internal use of hydrate of 
chloral, given with the potassium chlorate to a child of six years in about 
2J-grain doses. Herbert L. Snow recommends sulphurous acid, Dr. Hofmokl 
the hydrogen dioxide, and E. S. Smith the oil .of eucalyptus and Warburg's 
tincture. In diphtheria, therefore, as in other diseases which in a large pro- 
portion of cases end favorably whatever the treatment, the number of recom- 
mended remedies is large. 

Local Treatment — Solvents. — The belief is becoming prevalent in the 
profession that the early destruction and removal of the exudate from the 
faucial or nasal surface is not an imperative duty, as was formerly practised 
under the teachings of Bretonneau and Trousseau, provided that thorough 
disinfection of the pseudo-membrane and the surrounding and underlying 
tissues be effected. Patients are injured by irritating lotions or instrumental 
treatment designed to remove the pseudo-membrane, which immediately reap- 
pears in greater extent and thickness than at first, on account of the increase 
in the inflammation in consequence of the severe measures employed. The 
employment at short intervals of mild but ef&cient antiseptic applications in 
place of the stronger and irritating lotions formerly used has been a great 
improvement in the treatment of diphtheria. But antiseptic lotions, vapors, 
or sprays are inadequate to produce complete disinfection if the'pseudo-mem- 
brane has great thickness. Its under surface, which is in immediate relation 
with the lymphatics and blood-vessels, and from which systemic poisoning 
occurs from absorption of the diphtheritic germ, septic matter, or ptomaines, 
is probably not reached by the antiseptic sprays or lotions as commonly 
employed. Any painless and unirritating application which diminishes the 
thickness of the pseudo-membrane by its solvent action, or, better, entirely 
dissolves and removes it, is therefore useful. Of the unirritating solvents, 
alkalies, pepsin, trypsin, and papayotin have been chiefly used, and have in 
the highest degree the confidence of the profession. The efiiciency of solvent 
treatment depends largely on the manner in which it is employed, the kind 
of instrument used, and the frequency of the application. The solvent agent 
heretofore most largely used has been lime-water or the spray of slaking 
lime. Its solvent action is probably due chiefly to its alkalinity, but its 
alkalinity and its solvent action can be greatly increased by adding to it the 
sodium bicarbonate. From observing its effects in a considerable number of 
cases the writer recommends with confidence the following formula : 

R. 01. eucalypti, ^ij ; 

Sodii benzoat., 3J ; 

Sodii bicarbonat., ,^ij ; 

Glycerinf^, %\] ; 

Aquae calcis, Oj. Misce. 

To be used with the hand-atomizer from three to five minutes every half- 
hour, or with the steam atomizer almost constantly. This alkaline spray 
not only exerts a solvent action on the pseudo-membrane, but also renders 
the muco-pus thinner, less viscid, and therefore so changes its character by 
diminishing its viscidity that it is more easily expectorated. 

The use of pepsin as a solvent is suggested from its well-known action in 
digesting nitrogenous substances. It has been employed with varying results. 
It is well known that some of the preparations in the shops are much more 

^ British Medical Journal. 



TREATMENT. 429 

active than others, and hence perhaps a chief reason for the difference in the 
results obtained. It is well to remind the reader that it should be employed 
alone or with an acid, for it is comparatively inert if used with an alkali. 

Rossbach states^ that he has used a solution of papai/otin^ or vegetable 
pepsin, frequently applied to the fauces. In young children a few minims 
may be placed on the tongue every five minutes. If the drug be good, he 
states that the membrane is dissolved in two or three hours. Dr. Jacobi 
says that this agent is readily dissolved in twenty parts of water.'-^ It may, 
he says, be brushed over the surface or used as a spray. Mixed with water 
and glycerin in greater concentration (1 to 4—8), it has been used by him 
with fair results. Dr. J. K. Bauduy, Jr., also writes favorably of the solv- 
ent action of papayotin on the pseudo-membrane.^ 

Trypnn^ unlike pepsin, is an active solvent in an alkaline medium, and it 
may be added to the alkaline mixture described above. Dr. F. C. Fernald 
relates the case of a boy of six and a half years who had perforation of 
each membrana tympani and began to complain of sore throat. A pseudo- 
membrane appeared upon the tonsillar portion of the fauces, and the right 
auditory canal was covered with a diphtheritic exudate, entirely occluding 
it, so that liquids did not flow from the external ear to the fauces as formerly. 
The ear was filled every half-hour with the following mixture : R. Trypsin., 
gr. XXX ; Sodii bicarb., gr. x. ; Aquae destillat., 5J. The pseudo-membrane grad- 
ually dissolved and disappeared, the passage through the ear and Eustachian 
tube became open, and the patient recovered.* Dr. E. N. Liell also relates 
a case in which trypsin apparently produced a solvent action on the pseudo- 
membrane. Probably, therefore, in the present state of our knowledge we 
can apply no better solvent mixture upon the diphtheritic pseudo-membrane 
than trypsin added to the alkaline solution described above. 

Albuminuria. — This being due to septic nephritis, patients have seemed 
to me to be more benefited by the tincture of the chloride of iron, in fre- 
quent and rather large doses, than by any other remedy. If while this is 
being used a marked diminution in the quantity of urine occurs, it may be 
necessary to employ diuretics and laxatives, as in scarlatinous nephritis. 
The potassium bitartrate or acetate, and perhaps the more laxative salines, 
may be needed under such circumstances. But marked diminution of urine 
— and especially anuria — in diphtheria ends fatally, with few exceptions, 
according to my observations, whatever the treatment. 

Paralysis. — The loss of the tendon reflexes, and palatal and multiple 
paralysis, require the same stimulating and sustaining remedies which are 
appropriate for the primary disease, diphtheria. Iron and other tonics, nutri- 
tious and easily-digested diet, massage, and in some instances electricity, 
sufiice to restore the use of the affected muscles, but sometimes weeks and 
even months elapse before their use is fully restored. So long as the paraly- 
sis does not affect any vital organ, a favorable prognosis may be expressed, 
although recovery may be slow. 

On the other hand, it is evident from its nature and from the cases 
which have been related that cardiac paralysis is exceedingly dangerous, 
and must be treated promptly and by the most active remedies. As we 
have seen, the attack of cardiac paralysis is usually sudden, with little fore- 
warning, and is often fatal before the physician, promptly summoned, is 
able to arrive. The patient should be as quiet as possible in bed, with the 
head low. and alcoholic stimulants should be administered at once. In the 
sudden seizures, such as have been related above, hypodermic injections of 
brandy act most promptly in sustaining the heart-action. Ammonia, cam- 

^ St. Petersburg, med. Wochenschr., 1886. ^ New York Medical Record. 

^ Medical Weekly Review. * Medical News. 



430 DIPHTHERIA. 

phor, musk, and tlie electrical current may be useful auxiliaries. The pre- 
digested beef preparations, peptonized milk, and other concentrated foods 
designed for those with feeble digestion are useful. If the urgent symp- 
toms are relieved by these measures, such remedies should be employed as 
are useful in other forms of diphtheritic paralysis. The patient is ordinarily 
feeble, ansemic, and with poor digestion. The beef extracts and concentrated 
foods should be continued. Iron, quinine in moderate doses, and alcoholic 
stimulants are indicated. The use of the electric current is suggested by 
the nature of the attack. Many physicians believe that they have obtained 
benefit from its use in the treatment of the more common forms of diphthe- 
ritic paralysis, while others speak doubtfully of its efficacy. If there be 
reason from the symptoms to suspect the presence of central lesions in the 
nervous system, the galvanic current in short sittings has been recommended, 
and not the faradic. In ordinary cases either the direct or the induced cur- 
rent may be employed. 

Strychnine is, however, regarded by good observers as the most efficacious 
nerve-stimulant in the various forms of diphtheritic paralysis. Oertel's 
objection, expressed twenty years ago, to the use of strychnine in this disease, 
that, acting as an excitant of the spinal cord, it is likely to aggravate central 
lesions, was founded on a wrong understanding of the pathology of the 
paralysis. Prof. Henoch cured diphtheritic paralysis in three weeks by 
hypodermic injections of strychnine. W. Reinard^ states that a boy three 
and a half years of age fifteen days after the appearance of the diphtheritic 
patches on the tonsils had paralysis of the inferior extremities and the velum 
palati, a tottering gait, nasal voice, and difficult deglutition. At the end of 
twelve days death seemed imminent, the paresis of the lower extremities had 
become a complete paraplegia, and the paralysis of the upper extremities and 
of the muscles of the nucha, larynx, and thorax was complete. He was 
unable to sustain himself in the sitting posture, his head falling heavily on 
his chest. He had also dyspnoea, hoarse cough, tracheal rales, and aphonia, 
probably from cardio-pulmonary paralysis. Reinard made a hypodermic 
injection each day of one milligramme (about one-sixty-fifth of a grain) of 
sulphate of strychnine in the nucha. Improvement occurred in twenty-four 
hours in the tonicity of the muscles. On the third day the cardiac and pul- 
monary paralysis had so improved that the tracheal rales had ceased. The 
respiration was more normal and deglutition possible. On the fifteenth day 
of this treatment and after fifteen injections the patient was considered 
cured. Dr. Grerasimow ^ relates the case of a child six years of age who had 
paralysis of the velum, pharynx, larynx, and lower extremities. Six weeks 
after the commencement of paralytic symptoms subcutaneous injections of 
strychnine, two centigrammes (or about one-thirty-first of a grain), were 
given daily. With this treatment the patient improved, and after seven 
injections of this strength, followed by twelve of one-twenty-second of a 
grain, the cure was complete. 

With such strong testimony in favor of the use of strychnine, it is per- 
haps remarkable that physicians of experience state that they have not 
observed any marked benefit from its use in the treatment of diphtheritic 
paralysis. At a meeting of the New York Clinical Society, held December 
23, 1887,^ Dr. Holt stated that he was yet to be convinced that strychnine 
possessed any specific value in this disease, though it was of much value as 
a general tonic. At the same meeting Dr. A. A. Smith stated his belief that 
tonics and time did more for diphtheritic paralysis than anything else. He 
had used electricity and strychnine, and had never been able to satisfy him- 

1 Deutsche med. Wochenschr., 1885, No. 1 9. '^ Med. Obosr., No. 20. 

^ New York Medical Journal, Jan. 14, 1888. 



PERTUSSIS. 431 

self that electricity did any good, and the eiFects of strychnine seemed to be 
not specific, but those of a general tonic. On the other hand, Dr. Thatcher 
of New York has reported a case in which galvanism was employed on the 
two paralyzed upper extremities alternately, on each for a week at a time. 
It was invariably found that the arm receiving the electricity gained more 
rapidly than the one untreated, the strength being tested by the dynamom- 
eter. This test seems to have been conclusive as showing the efficacy of 
galvanization. 



CHAPTER YIII. 

PEETUSSIS. 

Pertussis is a highly contagious disease attended and manifested by a 
catarrh of the air-passages. This catarrh gives rise to a cough which does 
not differ, during the inception and in the declining period, from that in an 
ordinary catarrh, but during the middle period of the malady is spasmodic. 
Exceptionally, the system is so mildly affected that the spasmodic element of 
the cough is lacking through the whole course of the malady or is confined 
to a brief period. This distinctive symptom — namely, the peculiar cough — 
has been attributed to the irritating and disturbing action of the specific 
principle on the nerves which control the muscles of respiration. It is 
attributed to the impression produced upon the filaments of the pneumogas- 
tric, especially upon those of the internal branch of the superior laryngeal 
nerve, by the mucus which collects in the larynx and trachea, and which is 
known to contain the contagious principle in~ abundance. This cough con- 
sists in a series of forcible and loud expirations, followed by a noisy and 
difficult inspiration. Its special character is due to spasmodic contraction of 
the muscles of expiration, and notably of the small muscles of the larynx, 
so as to produce narrowing or even closure of the aperture of the glottis. 
Each paroxysm of the cough usually ends (not always) in the expectoration 
of viscid mucus. With rare exceptions pertussis affects the same individual 
but once. Rilliet and Barthez report a case of its second occurrence, and 
West another case. I have attended two adult patients, both women of 
intelligence, who stated that they had had previous attacks in early life. 
Pertussis usually prevails as an epidemic, but is occasionally sporadic, at 
which time its type is mild. It is highly contagious through the breath of 
the patient or from exhalations from his surface. Pertussis is probably a 
disease of antiquity, but there is no clear description of it prior to the six- 
teenth century. Some have thought that it was alluded to in the writings 
of Hippocrates, and the Arabian physician Avicenna who lived in the tenth 
century, in describing the " violent cough of children," which is attended by 
the spitting of blood and lividity of the face, probably alluded to it (Rilliet 
and Barthez). Baillon in 1578 described a cough which appeared in Paris, 
attacked chiefly children, and was so violent that it caused bleeding from 
the nose and mouth, and often vomiting. Willis in 1682 and Schenck in 
1695 also described a convulsive cough which we can apparently identify 
as pertussis. In the eighteenth century whooping cough was described by 
many observers in different parts of Europe, among whom we may mention 
Alberte (1728), Brendel (1747), De Basseville (1752), Forbes (1755), Cullen, 
Butter, and Danz. In the present century, whooping cough, being eminently 



432 PERTUSSIS. 

contagious and of such a nature that the patients are allowed to mingle in 
society, is widely disseminated, and epidemics of it are of frequent occur- 
rence. 

Incubative Period. — It is not improbable that this varies in different 
cases. Some writers believe that it is usually from two to seven days. In 

one instance I was able to ascertain it accurately. Mrs. B , having a 

cough for two weeks, which was afterward ascertained to be that of pertussis, 
came from Boston to a family in New York. She remained with this family 
from 2 p. M., January 2, 1879, till the evening, when she left the city. 
During her stay she held and kissed an infant that was previously well and 
had never been removed from the floor on which it was born. Pertussis was 
not at that time prevailing in New York. On the 6th, or four days after 
exposure, the infant began to cough, and this proved to be the beginning of 
a severe attack. 

Age. — Most cases of pertussis are between the ages of one year and 
eight years, but it occasionally occurs in adults and even old people who 
have not been attacked previously. It is rare under the age of three 
months, but through the kindness of Dr. Ewing of New York I was enabled 
to see a new-born infant with pertussis whose mother had had the disease 
during the two months preceding her confinement. This infant was fifteen 
minutes old, and during the washing had the first convulsive seizure, which 
appeared to consist chiefly of a spasm of the laryngeal muscles, with tempo- 
rary suspension of the respiration, and attended by deep lividity of the fea- 
tures, with some frothing from the mouth. These attacks occurred nearly 
every hour, with intervals of complete cessation of symptoms. The mucus 
between the lips finally became stained with blood, and death occurred on 
the third day. The mother, the intelligent wife of a clergyman, believes 
that the infant had similar attacks before its birth, for she frequently expe- 
rienced in the last weeks of gestation what seemed to be strong convulsive 
movements in the foetus, the duration of which corresponded with that of 
the attacks in the infant. A similar case is related by Rilliet and Barthez,^ 
and another by Keating.^ These cases throw light on the pathology of per- 
tussis, for they show that the specific principle may enter the blood. 

Causes. — Climate, race, and nationality do not seem to exert any decided 
influence on the spread of pertussis. Females are somewhat more liable to 
be attacked than males and, as we have seen, a large majority of the cases 
occur between the ages of one and ten years. Letzerich about the year 
1870 supposed that he had discovered the cause of pertussis in a microbe, 
which, received upon the surface of the air-passages in inspiration, increases 
rapidly and produces the spasmodic cough by its irritating action or the irri- 
tating properties which it imparts to the mucus. In the first stage of per- 
tussis he found only the spores of the microbe, and at a more advanced 
stage, in addition to the spores, he discovered filaments. He placed 
mucus holding the cryptogam upon the fauces of the rabbit, and witnessed 
the production of pertussis in this animal. Recently, Burger^ of Bonn 
states " that the micro-organism of pertussis is visible with a power of 340 to 
600 diameters, appearing as little rods of unequal size. With a higher power it 
is seen that the rods have the biscuit form. The groups of bacteria are irreg- 
ularly disseminated or disposed in line, and bear some resemblance to the 
leptothrix buccalis. The method of preparation is very simple. A small quan- 
tity of the expectoration is pressed between two cover-glasses, exposed to the 
flame of a Bunsen burner to coagulate the albumen : the coloring matter is 

^ Treatise on the Diseases of Children. 

^ System of Medicine by American Authors: Lea Bros., Philadelphia, 1885. 

^ Berlin, klin. Wochenschrift ; London Medical Record, May 15, 1884. 



PATHOLOGICAL ANATOMY. 433 

then added (watery solution of fuchsin or of methyl violet) ; it is then 
washed thoroughly in water, or the coloring matter removed by washing in 
alcohol, the bacteria alone remaining colored. These bacilli are not found in 
any other expectoration ; they are so abundant that it is difficult to contest 
their action ; their frequency is always in direct relation with the inten- 
sity of the disease." Dr. Poulet^ also confirms the statement of a special 
micro-organism in pertussis from his examinations. In the St. Peter shurgher 
mecl. TrocA., 1887, a " careful observer," Dr. Afanasiefi", also states that he 
has discovered a bacillus in the sputum of pertussis which differs from all 
other bacilli. It occurs in the form of small rods, single, in pairs, or in 
chains. The length of the bacillus is 0.6 to 2.2 micromillimetres. Its cul- 
tures exhibit peculiar qualities. Inoculated in animals, it produces symptoms 
like those of human pertussis, and the air-passages of these animals exhibit- 
ed the appearance of congestion and catarrh. In the *S'^ Petershiirgher med. 
Woch.. in 1888, another distinguished Russian observer, Seintschenko, writes 
that after many experiments he is able to make the following statements: 
1. The bacillus of Prof. Afanasieff is specific ; 2. Bacilli may be found in 
the sputum about the fourth day of the disease, in some cases earlier ; 3. 
They multiply in the tissues of the body, and as they increase the severity 
of the disease increases ; 4. The bacilli disappear before the entire cessa- 
tion of the attacks of coughing, or when the paroxysms are reduced to two 
or four daily ; 5. With complications — such as, for example, a catarrhal pneu- 
monia — there is a great increase in the number of whooping-cough bacilli 
found in the sputum ; 6. A pneumonia developing under these circumstances 
differs from ordinary attacks of catarrhal pneumonia ; 7. The bacillus of 
whooping cough is of value, not only in etiology and diagnosis, but in the 
prognosis, of the disease. 

Lesions have been discovered in certain fatal cases which have been sup- 
posed to throw light on the etiology of pertussis, but which are now known 
to have been merely coincidences or results of the disease. Such are con- 
gestion of the spinal cord and its meninges, hyperemia of the pneumogas- 
trics, and tumefaction of the tracheo-bronchial glands, which it was claimed 
produced the spasmodic cough by compressing the recurrent laryngeal 
nerve. 

Pathological . Anatomy. — Catarrhal inflammation of the air-passages 
is uniformly present. It occasionally occurs on the mucous surfaces of the 
nostril and pharynx, but is often absent from these parts. In the majority 
of patients the inflammation affects the surface of the glottis and that below 
the glottis. Herff examined his own larynx during paroxysms of pertussis. 
He observed a moderate inflammatory hyperasmia of the respiratory tract 
during the entire course of the disease. The inflammation extended from 
the posterior nares to the bifurcation of the trachea, but was most marked 
in the following locations : over the cartilages of Santorini, Wrisberg, and the 
arytenoid, and the posterior wall of the larynx, between the vocal cords and 
the epiglottis, and on the under surface of the epiglottis. The vocal cords 
themselves were not affected. During the paroxysm a pellet of mucus was 
observed upon the posterior surface of the larynx on a level with the glottis, 
and when this was removed the cough ceased. Irritation of this part of the 
larynx uniformly excited a cough. Sometimes certain alveoli are found 
distended by a thick muco-pus, producing an appearance like minute 
tubercles. 

A common lesion found in the lungs of those who have perished with 
this malady is emphysema, affecting chiefly the peripheral portions of the 
upper lobes. It is usually vesicular emphysema, occurring from over-dis- 

^ La Scalpel ; London Medical Hecord, May 15, 1884. 
28 



434 PERTUSSIS. 

tension of tlie air-cells, but in some instances tlie air has escaped into the 
connective tissue, causing interstitial emphysema. According to my recol- 
lection of fatal cases which have occurred from time to time in the institu- 
tions of New York, and in which I have made post-mortem examinations, 
the upper lobes were exsanguine and inflated to nearly the fullest extent 
possible within the thorax, while other portions of the lungs presented areas 
of pneumonic or more or less complete atelectatic solidification. Pneumonia, 
atelectasis, and small extravasations of blood in the lungs are, indeed, com- 
mon lesions. Hyperplasia of the bronchial glands is also common, and 
hyperplasia has also been occasionally observed of other lymphatic glands, 
as the mesenteric. An ulcer under the tongue which observers have fre- 
quently noticed is now attributed to the pressure of the tongue on the lower 
incisors during the cough. 

In fatal cases small extravasations of blood in or upon the brain are com- 
mon, as is also passive congestion of the sinuses, veins, and capillaries, men- 
ingeal and cerebral, attended with more or less transudation of serum within 
the ventricles of the brain and between the meninges. Large dark and soft 
clots, and occasionally some that are white or yellow, are common in the 
intracranial sinuses, especially if, as often happens, death have occurred in 
convulsions which supervened upon the severe spasmodic cough. 

Symptoms. — Pertussis consists of three stages : first, that of catarrh of 
the air-passages ; secondly, the stage of spasmodic cough, or, for brevity, the 
spasmodic stage; thirdly, the stage of decline. 

The Jirst period is characterized by the symptoms of coryza and bron- 
chitis, which present nothing peculiar or different from ordinary catarrh of 
the same parts, unless occasionally the cough be more frequent and teasing. 
Trousseau has known it to be repeated forty or fifty times per minute. The 
eyes present a moderately suffused appearance, and there is sneezing, with 
defluxion from the nostrils, but less than in the commencement of measles. 
The cough, which begins as soon as the catarrh affects the larynx, is accom- 
panied by little or no expectoration. The pulse and respiration are moderately 
accelerated, and such other symptoms as commonly accompany catarrh of a 
mild grade are present — to wit, increased heat of surface, thirst, and impaired 
appetite. 

The duration of the first stage varies in different cases. In severe whoop- 
ing cough it may last only two or three days, and in mild cases be protracted 
to five or six weeks. It may be absent especially in very young infants. We 
have alluded above to the new-born infant, in whom there is no first stage, a 
glottic spasm occurring soon after birth. The first stage commonly ends in 
from eight to fifteen days. In fifty-five cases observed by Dr. West its aver- 
age duration was twelve days and seven-tenths of a day. It is stated above 
that the first stage in rare instances continues during the entire course of per- 
tussis ; at least no spasmodic cough occurs. In two such cases which I now 
recall to mind, both girls, the inflammatory symptoms abated somewhat after 
the first few days, and an occasional easy cough remained, like that of simple 
bronchitis, and it continued during a period corresponding with the ordinary 
duration of pertussis. The diagnosis would have been doubtful, except for 
the occurrence of pertussis, with its regular stages, in other children of the 
same families. 

Second Period. — This may commence quite abruptly, but ordinarily its 
beginning is gradual. While the cough commonly has the character present 
in the first stage, it is now and then observed to be more severe and spas- 
modic, especially at night and when the patient is in any way excited. The 
spasmodic element increases, so that in the course of a week all doubt as to 
the nature of the disease is removed. 



SY2IPT02IS. 435 

The severity of the cough in the second stage varies considerably in dif- 
ferent cases. It sometimes commences quite abruptly, with little warning, 
but commonly there is premonition of it, and the child endeavors to repress 
it. He experiences a tickling sensation in the throat or median line of the 
chest, or a feeling of constriction. He leaves his playthings and rests his 
head on his mother's lap or takes hold of some firm object for support; his 
face has a grave or even anxious appearance, while the pulse and respiration 
are somewhat accelerated. Immediately the cough begins. It consists in a 
series of short and hurried expirations, which expel a large part of the air 
contained in the lungs, followed by a hurried inspiration, which is difficult 
and noisy on account of the spasmodic contraction of the laryngeal muscles 
and narrowing of the glottic aperture. The sound which accompanies the 
inspiration, and which is often absent, especially in infants, is designated the 
whoop. The forcible expirations and difficulty experienced in expelling the 
air from the lungs on account of the constriction of the glottis afford expla- 
nation of the emphysematous distension of the air-cells in the upper lobes 
which we have seen is so common in severe pertussis. 

There may be a single series of expirations terminating in the manner 
stated, but often there are several such series embraced in a paroxysm. The 
cough commonly ends in the expulsion of frothy mucus from the bronchial 
tubes, and sometimes in vomiting. During the cough there is temporary 
arrest of blood in the lungs, leading to congestion in the right cavities of the 
heart and throughout the systemic circulation ; therefore the face is flushed 
and swollen, and occasionally hemorrhage occurs under the conjunctiva or 
from one of the mucous surfaces. The most frequent hemorrhage is epis- 
taxis. When the cough ceases, the normal respiration is restored, the fulness 
of the vessels immediately abates ; but often puffin ess of the features is 
observed, due to serous infiltration of the subcutaneous connective tissue, 
and continuing for days or weeks during the period when the cough is most 
severe. The paroxysm lasts from a quarter toa half or even a whole minute, 
and in that time, in cases of ordinary severity, there are often as many as fif- 
teen or twenty series of expirations. 

At the close of the paroxysm, if there be no complication, the symptoms 
soon abate ; the temperature, pulse, and respiration become normal, and there 
is no evidence of disease. The cough in the second stage is much more fre- 
quent in one case than another. At the height of this stage it is generally 
more severe if it occur at long intervals than when frequent. During the 
weeks in which pertussis is most severe there is, on the average, about one 
paroxysm of coughing in each hour. 

The cough increases in severity till the third week of the second stage, or 
the thirtieth to the thirty-fifth day of the disease, after which it remains sta- 
tionary for a certain time. It is apt to be more frequent in the night than 
day-time. Sometimes it occurs while the child is quiet ; it may even awaken 
him from sleep, but it is often also produced by mental excitement or by 
physical exertion. Anger or fright gives rise to it, and therefore the child is 
likely to cough when being examined by the physician or when his wishes are 
not complied with. The ordinary duration of the second stage is from thirty 
to sixty days. It may, however, be considerably longer or shorter than 
this. 

The third stage, which commences at the time when the spasmodic cough 
begins to abate, is short, not continuing longer than two or three weeks. A 
protracted stage of decline indicates some complication. While the sputum 
in the second stage is mucous and frothy, that in the third stage is more 
opaque and puriform. 

In the third as in the second stage, if there be no complication, the pulse 



436 PERTUSSIS. 

and respiration in the intervals of the paroxysms are nearly or quite natural. 
Febrile excitement may, however, now and then occur from trifling causes, or, 
indeed, without any apparent cause. The digestion and the general health in 
uncomplicated pertussis remain unimpaired, with the exception of more or 
less emaciation, which is likely to occur in all but the mildest cases in conse- 
quence of the frequent vomiting. After complete recovery it is not unusual 
for the spasmodic cough to reappear at times for one or even two years. The 
cough of ordinary simple laryngitis or bronchitis assumes this character. 

Complications. — These, like the symptons, are chiefly of a twofold 
character — to wit, inflammatory and neuropathic. From the nature of 
the cough in pertussis, it would naturally be supposed that the spasmodic 
aff"ection which is now designated internal convulsions, and which is charac- 
terized by spasm of certain muscles of respiration, would be a frequent com- 
plication. It does sometimes occur in young children, but it is not common. 
Clonic convulsions aff'ecting the external muscles are, on the other hand, not 
infrequent. They occur chiefly in the second stage, when the cough is most 
severe, and in infancy much more frequently than in childhood. They are 
likely to be general and severe, or, if not of this character at first, to become 
such. The convulsions commence in most instances in or directly after the 
paroxysm of coughing, but they sometimes occur in the interval when the 
child is quiet. 

Rilliet and Barthez remark : " Almost all infants succumb to this com- 
plication, ordinarily in the twenty-four hours which follow the first attack; 
nevertheless, life may be prolonged during two or three days " (article 
Coqueluclie) . In ni}^ own practice this complication usually ended fatally 
before bromide of potassium and chloral were employed, but with the proper 
use of these agents it can often be arrested. In the month of June, 1867, I 
was attending a little girl tw^o years and four months old who had reached 
the fifth week of pertussis when she was seized with general clonic convul- 
sions. The mother, who was requested to keep a record of the number of 
convulsions, stated that there were twenty in all occurring within forty-eight 
hours. They aff'ected both sides, the shortest lasting only three or four 
minutes, the longest seventy-five minutes. The treatment in this case, 
which eventuated favorably, will be noticed hereafter. 

In those w^io die of convulsions occurring in whooping cough the most 
constant lesion is congestion of the cerebral veins and sinuses, often with 
transudation of serum. This congestion is due in part to the cough which 
precedes the convulsions and in part to the convulsions themselves. At the 
autopsies which I have made of two infants who died in hospital practice 
from whooping cough, accompanied by convulsions, all the cerebral sinuses 
were filled with clots, which were generally soft and dark ; but in the lateral 
sinuses clots were found which were light-colored. The light color of a clot, 
either in a vein or sinus, indicates its ante-mortem formation. 

The gravity of the convulsive attack can be ascertained by observing 
whether the patient readily recovers consciousness. Its return indicates that 
there is no serious congestion. On the other hand, great drowsiness remain- 
ing or a semi-comatose state indicates persistent congestion, and perhaps even 
the formation of clots in the sinuses of the brain. Death from convulsions 
is usually preceded by coma. Occasionally meningeal apoplexy supervenes 
upon the congestion, and death is immediate. 

The most frequent inflammatory complications are bronchitis and pneu- 
monitis. Inflammation of the bronchial tubes of a mild grade, we have seen, 
is a common accompaniment of pertussis, but when it extends to the minuter 
tubes or becomes so severe as to cause acceleration of respiration, it is prop- 
erly a complication. Both bronchitis and pneumonitis, occurring as compli- 



COMPLICATIONS. 437 

cations, are developed, with few exceptions, in the second stage. Bronchitis 
is accompanied by accelerated respiration and pulse and increased tempera- 
ture. The danger is proportionate to the amount of dyspnoea. 

Pneumonitis is a less common complication than bronchitis, but it occurs 
more frequently in pertussis than in any other constitutional malady of early 
life, excepting measles. The congestion which results and remains in the lung 
when the cough is frequent and severe favors the development of pneumonia. 
The symptoms and physical signs which accompany this inflammation and 
serve for its diagnosis are the same as in the primary form of the disease, 
and are described elsewhere. Bronchitis or pneumonia usually moderates 
the severity of the spasmodic cough, for when the inflammatory element in 
pertussis increases the spasmodic abates. On the abatement of the inflam- 
mation, however, the cough usually regains its former convulsive character. 
The fact may be stated in this connection that any complication or intercur- 
rent disease which is attended by decided febrile reaction ordinarily renders 
the cough for the time less spasmodic. 

The occurrence of bronchitis or pneumonia is shown by the elevated tem- 
perature, acceleration of pulse and respiration, short and frequent cough. 
These symptoms do not cease so long as the inflammation continues, whereas 
in uncomplicated pertussis the patient seems nearly or quite well between the 
coughs. In pneumonia the respiration is accompanied by the expiratory 
moan, and in both bronchitis and pneumonia there is more or less depression 
of the inframammary region during inspiration. These symptoms, in con- 
nection with the physical signs, render diagnosis in most instances easy. 
Although the general character of the cough is changed, a cough now and 
then occurs, even when the inflammation is pretty severe, sufficiently spas- 
modic to indicate the nature of the primary aff"ection. Capillary bronchitis 
and pneurqonia are always serious complications. 

Xot only is more or less emphysema a common complication of severe 
pertussis, but bronchiectasis also occurs in certain cases, due to the same 
conditions. Emphysema is a common lesion in young and feeble infants, 
even when there is no history of any previous severe disease of the respira- 
tory organs. I have found it one of the most common lesions in infants of 
feeble constitutions who die in the hospitals and asylums of New York, but 
it is usually interstitial and confined to a small part of the upper lobes. It 
is not accompanied by that general distension of the alveoli and consequent 
enlargement of the lobes which occur in the emphysema of pertussis. Its 
chief cause in these feeble and wasted infants appears to be impaired nutri- 
tion and change in the molecular state of the pulmonary tissue. The same 
molecular change often occurs in severe and protracted pertussis, and there- 
fore serves as an additional and efficient cause of the emphysema. 

The following was a not unusual case of this disease as it occurs in the 
tenement-houses and asylums of New York. At the meeting of the New 
York Pathological Society, October 14, 1868, I exhibited emphysematous 
lungs removed from an infant who died at the age of nineteen months at 
the commencement of the fourth week of pertussis. Death occurred from 
thrombosis in the lateral sinuses of the cranium, resulting from the severe 
spasmodic cough, eclampsia, and feebleness of the circulation, as the infant 
was previously in a reduced state from chronic entero-colitis. At the autopsy 
the superior lobes of both lungs were found exsanguine, doughy to the feel, 
and enlarged so as to rise above the level of the other lobes. The resiliency 
and elasticity of the lung-tissue in these lobes were evidently greatly impaired, 
and their air-cells in a state of over-distension. The other lobes were healthy, 
except that one of them was the seat of catarrhal pneumonia. In this case 
there had been no disease aff"ecting the respiratory apparatus previous to the 



438 



PERTUSSIS. 



pertussis, so that the incipient vesicular emphysema was referable to the 
severe cough and impaired nutrition of the lungs. 

Occasionally we meet cases of severe pertussis in which, while there is 
over-distension of the alveoli of the upper lobes, collapse occurs over a greater 
or less extent of the lower lobes. Collapse, like emphysema, may continue 
for weeks or months subsequently to pertussis, and then gradually disappear, 
but in the following case, rare in my experience, it was permanent: John 
O'Neil, aged five and a half years, was brought to the Bureau for the Belief 
of the Out-door Poor in New York in December, 1876. He lived in the 
underground basement of a tenement-house, and was supported by charity, 
except at intervals, when his father, who was dissipated, could obtain work. 
At the age of fifteen months he had a glandular swelling on the right side of the 
neck, which suppurated, and three months later one on the opposite side, which 
also suppurated. At the age of two and a half years he had bronchitis, 
the cough of which did not abate till two months subsequently. When near 
the age of three years he had measles, and the cough from this disease lasted 
three or four months. In the summer of 1875, or about one year subse- 
quently to the measles, he contracted pertussis, which was severe, but was 
allowed to run its course without treatment. It lasted four months, never, 
however, confining him to bed or materially impairing his appetite. One 
morning about the close of the second month of the malady the parents first 
observed depression of the right side of the thorax. This gradually increased 
a few weeks, and has been permanent. The parents stated that he had never 
been confined to the house or without appetite except during the week of 
measles. 

Since his recovery from pertussis he has had his usual appetite and gen- 
eral health, but crying or excitement commonly brings on a pretty severe 
cough. The depression of the thorax, examined in 
front, begins quite abruptly in the line of the left 
costo-chondral articulations. Circumferential meas- 
urement of the left side from the middle of the 
sternum to the spine, the tape lying a little below 
the nipple, gives eleven and a half inches, while cor- 
responding measurement of the right side gives seven 
and a half inches ; pulse 136, sounds of the heart nor- 
mal ; respiration 44. On auscultation over the right 
side of the chest we observed bronchial respiration 
and a feeble bronchophony, with perhaps slight vocal 
fremitus. The accompanying figure is from a pho- 
tograph by Mr. Mason, photographer to Bellevue 
Hospital. My first impression on observing this 
case was that it was one of unexpanded lung which 
had been compressed by a pleuritic eifusion, but it is 
seen that the history points clearly to pertussis as 
the cause of the deformity. The depression oc- 
curred somewhat suddenly when the cough was most 
severe and when there was no fever, loss of appetite, 
or other symptom of pleuritis. The patient had not 
presented any marked evidence of rachitis, but was 
decidedly strumous. 

Pertussis is sometimes complicated by the erup- 
tive fevers. There does indeed seem to be some 
affinity between it and measles, so that many epi- 
demics of the two have been observed at about the same time. During my 
term of service in the New York Foundling Asylum, in May, 1878, measles 



Fig. 28. 




niA GNOSIS. 439 

and pertussis prevailed in the wards at the same time. Eighteen of the' 
children who were having pertussis contracted measles, and the Sisters, who 
were very intelligent and faithful observers, and were requested by me to 
notice the effect of the complication, stated that with few exceptions the 
severity of the whooping cough was increased during the continuance of 
the exanthem. This is contrary to the general belief of the effects of 
intercurrent febrile diseases. 

Diagnosis. — During the period of invasion it is impossible to diagnosticate 
pertussis. Its nature can only be conjectured from a known exposure or from 
the epidemic occurrence of the disease. In the second stage, which is cha- 
racterized by the spasmodic cough, diagnosis is ordinarily easy, and often the 
parents are able to announce the nature of the disease when the physician is 
called. Still, a mistake is sometimes made : a spasmodic cough very similar 
to that of pertussis occasionally occurs in other maladies. Young infants 
with bronchitis frequently experience great difficulty in the expectoration of 
mucus, which collects in the air-passages and provokes a suffocative cough. 
The following facts will aid in making the diagnosis : Bronchitis, accompanied 
by a suffocative cough, is an acute disease, and the cough occurs at an early 
period, usually in the first week. It lacks the inspiratory sound or the whoop, 
and is associated with constantly accelerated respiration and well-marked febrile 
symptoms, dependent on the inflammation. Moreover, the cough is occasion- 
ally suffocative, according to the amount of mucus in the tubes. The spas- 
modic cough of pertussis, on the other hand, is preceded by the stage of inva- 
sion, and it occurs only in the second stage, when the febrile symptoms have 
abated. Again, the suffocative cough of bronchitis rarely ends in vomiting, 
which is common in the cough of pertussis. 

The only other disease with which there is much likelihood of confound- 
ing pertussis is bronchial phthisis. The points of differential diagnosis are 
the following : the one epidemic and spreading by contagion, the other non- 
contagious and isolated ; the one embraced in .three distinct stages and much 
shorter, the other chronic and presenting no stages, but commencing with 
mild, non-febrile symptoms and progressively becoming more severe ; in the 
one an absence of symptoms in the intervals of the cough, provided that 
there be no complication, in the other constant symptoms, such as are com- 
mon in tubercular disease. The previous health and the presence or absence 
of a tubercular cachexia should be considered in determining the nature of 
the disease. Usually in bronchial phthisis the lungs are also affected, so that 
auscultation and percussion may furnish positive proofs of the nature of the 
cough. 

The attacks of suffocative cough which are produced by the lodgment 
of a foreign body in the larynx or lower down in the air-passages bear a 
close resemblance to those of pertussis. The diagnosis can be made by the 
history, for in the one case there is a preliminary catarrhal stage, and in the 
other the cough begins abruptly, and usually after the known swallowing of 
the offending substance, which produces dyspnoea and a spasmodic cough as 
soon as it enters the larynx. The presence of the body can also be deter- 
mined in a large proportion of cases by the laryngoscope and auscultation. 

Prognosis. — A larger proportion doubtless recover under the better ther- 
apeutics of the present time than in former years. According to Hirsch 
(ii. p, 105), 72,900 persons perished from this disease in England and Wales 
between 1848 and 1855, or 1 in every 40 who died; and Wilde's reports 
show that it stands fifth as regards mortality among the epidemic diseases 
of Ireland. In New York City, during the half century ending with 1853, 
4840 died of pertussis, or 1 died from this disease in every 76 of deaths 
from all causes. 



440 PERTUSSIS. 

As a rule, the older the child the better the prognosis. Young infants 
may die of suffocation due to the glottic spasm. Eclampsia with extreme 
passive congestion of the encephalon is a not infrequent complication in 
children under the age of five years, and it is apt to terminate fatally. It 
may, however, be averted in most cases by proper treatment when threaten- 
ing. In rare instances death may occur in or immediately after a paroxysm 
of coughing, in consequence of rupture of a cerebral or meningeal vessel 
and the eftusion of blood, or from stasis and coagulation of blood in the 
venous system, especially if convulsions have supervened upon frequent 
and protracted paroxysms of coughing. Other complications which are 
likely to arise under conditions which favor their development, and which 
greatly increase the danger and render the prognosis unfavorable, are capil- 
lary bronchitis, pneumonia, diphtheria, and in the summer season intestinal 
catarrh. 

Feebleness of system and antecedent and accompanying chronic disease 
increase the danger. Pertussis sometimes produces so much emaciation and 
loss of strength, in consequence of the severity and frequency of the cough 
and the repeated vomiting, that intercurrent diseases which in favorable 
states of the system would probably end in recovery are very apt to prove 
fatal. 

I usually inform the family that the patient is doing well if he seem 
entirely well between the paroxysms ; but if he appear ill, whether with som- 
nolence, fretfulness, fever, loss of appetite, accelerated breathing, or diarrhoea, 
he is not doing well, and probably has some complication which requires 
attention. 

Treat3IENT. — In the catarrhal stage the treatment should be the same 
as in mild idiopathic bronchitis. Demulcent and soothing cough mixtures 
are required. Care should be taken to employ nothing which reduces the 
strength or impairs the general health. If there be much bronchitis with 
accelerated breathing and frequent cough, mild counter-irritation to the chest 
and the use of the oil-silk jacket are proper. 

Therapeutic measures are chiefly indicated in the second stage or that 
of convulsive cough. Proper treatment may control the severity of the 
cough, and abridge the duration of the second stage, and prevent or control 
complications. Pertussis has received a great variety of treatment. The 
enumeration of the medicines and modes of treatment which have had their 
season of repute and been employed by intelligent physicians would occupy 
too much time. The treatment should vary in some respects according to 
the case, but a small number of medicines suffices even in the most severe and 
obstinate forms of the malady. Knowledge and appreciation of the patho- 
logical state in pertussis assist us to the choice of the proper remedies. The 
specific principle of pertussis produces but little depression of the vital pow- 
ers. It does not impair the appetite by its direct action on the nutritive 
function, nor does it produce those profound blood-changes which we observe 
in scarlet fever and diphtheria. It afi"ects the system injuriously by the sever- 
ity of the cough, the vomitings and consequent loss of nutriment, and the 
complications which frequently occur, some of which involve fatal conse- 
quences. 

Remedies are required which diminish the sensitiveness of the laryngo- 
tracheal surface, which destroy the specific principle in those parts where the 
local manifestions of the disease occur, or control its action ; that is, in the 
larynx and trachea. The use of inhalations is at once suggested as most 
likely to fulfil the indications, since by inhalation the medicine employed is 
brought into immediate contact with the parts which are chiefly concerned 
in the disease. 



TREATMENT. 441 

Onholic Acid. — During an epidemic of pertussis a few years since in 
the New York Foundling Asylum, after trial of the older remedies without 
any marked result, carbolic acid, half a drachm to eight ounces of glycerin 
and water, was employed by inhalation from three to six minutes, and at 
intervals of two to six hours according to the severity of the cough. The 
result was apparently better than with the other remedies, since the cough 
became less frequent and severe. Carbolic acid seems to have an anass- 
thetic effect on the laryngo-tracheal surface. It is also an efficient anti- 
septic and germicide agent, so that if inhaled frequently it probably 
destroys the specific principle in the mucus and epithelial cells of the air- 
passages. It has been in my practice conveniently employed in the croup- 
kettle. Three teaspoonfuls of the saturated solution of carbolic acid are 
added to water sufficient to cover the bottom of the croup-kettle to the depth 
of two inches, and when it is brought nearly to the boiling-point, the vapor is 
inhaled a few minutes every hour or second hour through the tube. If an 
equal quantity of the oil of eucalyptus be added, the inhalations are more 
agreeable and the germicide effect is probably increased. Dr. Keating^ rec- 
ommends the following formula for inhalation : 

R. Acidi carbolici cryst., gr. iij ; 
Sodii biborat., 

Sodii bicarb., da. gr. x ; 

Glycerinse, 

Aqase, da. 3J. 

An alkali, as in the above mixture, is believed to render the mucus more 
fluid, and water, even when not medicated, increases its fluidity and ren- 
ders expectoration more easy. Pick also highly recommends carbolic acid 
in the treatment of pertussis (Archiv f. Kinderheilk..^ 1886), and believes 
that when not effectual it is too much diluted. He adds fifteen to twenty 
drops to a roll of cotton, which is introduced into a mask. The patient 
inhales the vapor of the gas several times each day, and the cotton wad is 
renewed three times. The duration and severity of the disease were dimin- 
ished by the inhalation, and no ill results occurred in any case. Miller has 
also used carbolic acid internally in doses of one minim in children over the 
age of five, with, he states, good results ; but its use by inhalation appears to 
be equally or more effectual, and is devoid of the risks which attend its 
internal use (^Medical Register, 1888). 

Cocaine. — This has been quite largely used as an application to the throat 
on account of its anaesthetic effect, but its action is evanescent, so that in 
order to obtain the full benefit from its use it is necessary to apply it often. 
Labrie states that the repeated application to the throat of a 5 per cent, solution 
immediately diminishes the number of paroxysms (^Lond. Med. Rev.., 1888). 
Holt, in discussing the safety of its use (A^. Y. Med. Jour..^ 1888), states, 
" 1st, It must be used with great caution in young children under all cir- 
cumstances ; 2d. The spray is never to be recommended, since an uncertain 
quantity is given ; 3d. Solutions stronger than 4 per cent, should not be 
used in children under two years ; 4th. In cases where it was tried he failed 
to see any notable benefit." Probably cocaine will not come into general 
use, because frequent applications would be necessary in order that its effect 
be continuous, and this would apparently be dangerous ; still, it might be occa- 
sionally used in order to obtain temporary respite from the cough when it 
involves danger in consequence of its frequency and severity. 

Antipyrine. — This agent is now largely used, and many physicians have 
written in its favor. Sonnenberger regards it as a specific (^Therapeut. 

1 Medical Ntws, Feb. 28, 1885. 



442 PERTUSSIS. 

Monatschrifte, 1888). He prescribes it in doses of as many centigrammes 
(one-sixth grain) as the child is months old, and as many decigrammes (one 
and a half grains) as it is years old, three times daily. He says that the 
earlier it is employed the better is the result. Genser administers only one 
and a half grains daily for each year of the age, and he found that it dimin- 
ished the frequency and severity of the cough {^Algemeine Med. Cont. Zeit., 
1888). Laborderie reports the complete cure of pertussis by the use of 
antipyrine in twelve to sixteen days. He says: "(1) Children take anti- 
pyrine without difficulty, and as a rule easily bear its effects ; (2) The spas- 
modic condition is rapidly calmed, and in a few days the disease declines ; 
(3) Its action is so prompt and free from accidents that it becomes a valuable 
remedy in a malady which may be of prolonged duration and give rise to 
many complications " (Bvll. gen. de Therap.., 1888). In my practice anti- 
pyrine has also in some cases been a very important remedy, reducing the 
severity of the paroxysms. I have administered it in small or moderate 
doses every third or fourth hour in combination with an alcoholic stimulant. 
Antipyrine is especially useful in cases attended by fever. 

Quinine. — The use of quinine in whooping cough was strongly recom- 
mended by Binz, who attributed the good effects which he had observed to its 
germicide action. It has been employed with apparently good results, both 
locally and internally. Kolover prescribes the following solution as a spray : 
R. Quiniae sulph., gr. 50 ; Acidi sulphur., gtt. 30 ; Aquas destillat., g5f . The 
fauces are sprayed with this every two hours for the first three days, and 
three hours for the rest of the week, when treatment is no longer necessary 
(i>' Union Med.^ 1887). Bachen employs insufflation into the nostrils of fifteen 
grains of a finely triturated powder of twenty parts of quinine and one of 
benzoin (Lond. 3Ied. Rec, 1887). Swett also prescribed the insufflation of 
quinine morning and evening, and observed improvement after the first day. 
Forchheimer and the late Prof. Rochester have likewise recommended the local 
use of quinine. The internal use of quinine has been supposed to be useful 
by diminishing reflex irritability (Schlakow and Eulenberg). It is undoubt- 
edly a useful remedy in those common cases in which febrile symptoms arise 
from bronchitis or broncho-pneumonia. 

Paulet^ recommends the evaporation, over a suitable fire, of 

R. Spirits of thvmol, grammes 10 
Alcohol, " " 250 

Water, " 750 

Keating also recommends the same agent in the follwing formula : 

R. Thymol, gr. xv ; 

Alcoholis, ,^iij ; 

Glycerinae, ,^ss ; 

Aquse, ^xxxiv. Misce. 

Internal remedies, formerly much used, now occupy the second place in 
the therapeutics of pertussis. Belladonna has been largely employed, since . 
it appears to diminish the spasmodic element in the cough of pertussis. 
Brown-Sequard, in remarks made before the United States Medical Associa- 
tion in May, 1860, maintained that the duration of pertussis, so far as its 
nervous element is concerned, might be abridged to a few days by doses of 
atropia sufficiently large to cause toxical effect ; but in one case which I saw 
in consultation, in which one teaspoonful of tincture of belladonna was given by 
mistake to a child of about three years, the subsequent cough, though mild, did 
1 London Medical Record, May 15, 1884. 



TREATMENT. 443 

not lose its spasmodic element. Children require a larger proportionate dose of 
belladonna than adults, and it can be safely administered in gradually increas- 
ing doses until physiological effects are produced, when some mitigation in 
the cough may be expected. Probably the action of the drug is on the 
respiratory centres in the medulla, and not directly on the muscles of respira- 
tion. The effect of belladonna in controlling the spasmodic cough is most 
marked when physiological symptoms are produced, and some children require 
larger doses than others. Thus I gradually increased the doses of belladonna 
to twelve drops for a child of three and a half years who had severe pertussis, 
without producing the characteristic efflorescence, while smaller doses from 
the same bottle produced this effect in older children. Rarely I have discon- 
tinued the belladonna on account of diminished flow of urine, which this 
agent may or may not have produced, and very rarely on account of suddenly 
developed muscular weakness, which I had reason to think the belladonna 
caused. This occurred in the case alluded to above, in which twelve drops 
of the tincture were given, so that the muscles seemed flabby and the trunk 
and head were supported with difiiculty. The tincture of belladonna is con- 
venient for use, and most of that in the shops is active and reliable. The 
doses which I ordinarily found to be sufficient when prescribing belladonna 
for pertussis, and which also produced efflorescence, were as follows : to a 
child of two years three drops, and to one of six or eight years eight or ten 
dr^ps, morning and evening. I always, however, commenced with a smaller 
number, and continued to administer the dose which produced the local effects 
alluded to, unless the cough were moderated by smaller doses. In the majority 
of cases I have noticed no decided effect till the rash was produced, when the 
symptoms improved, the cough becoming less frequent or less severe. By 
the belladonna treatment the spasmodic stage may not only be rendered mild, 
but be abridged to two or three weeks. In some cases the severe cough begins 
to yield almost immediately under full doses of this agent, but in other cases 
its continuance for some days is necessary, with other remedies as adjuvants, 
before there is any appreciable benefit from its use. But since the germicide 
treatment of pertussis has come into use, it is probable that belladonna will 
be entirely superseded by those agents which are believed to exert a destruct- 
ive effect on the supposed cause. 

Sulphur. — Much benefit is said to result from fumigating the room 
occupied by the patients with burning sulphur. The children having the 
disease are attired in clean clothes and removed, and the room which they 
have occupied, containing the furniture, clothes, and toys, is fumigated five 
hours with burning sulphur, after which the doors and windows are thrown 
open. The children sleep in the same room during the following night. 
Immediate improvement is said to follow. This treatment of pertussis is 
recommended by Manby, Grelhert, Mohn, and others. 

The distinguished Brazilian physician Moncorvo advises, and uniformly 
employs, local treatment with a solution of resorcin. In an interesting paper 
read before the Pediatric Section of the Ninth International Medical Con- 
gress in 1887 he states that he employs resorcin as a local antiseptic on 
account of its slight irritating properties, its great solubility, and its absence 
of odor. Beginning with a 1 per cent, solution, he had increased it to 8 per 
cent. He first applies to the periglottic region a 10 per cent, solution of 
hydrochlorate of cocaine, which diminishes the reflex excitability of the laryn- 
geal mucous membrane and renders the paroxysms less frequent, and then 
applies the resorcin. 

Bleyer recommends the use of the peroxide of hydrogen (H2O2) as the 
most powerful antiseptic and germicide in existence. He sprays the laryngeal 
space with the following : 



444 PERTUSSIS. 

R. Ch. Marchand's peroxide of hydrogen (15 vol. chemically pure), ^j ; 

Aquse, ' ' ^v. 



At the same time the nares are irrisfated with the folio win 



R. Peroxide of liydrogen, ,^ij ; 

Aquse, Jiij. Misce.^ 

Previously, Dr. B. W. Richardson had stated that he obtained good results 
from drachm doses of the peroxide given five or six times daily. ^ 

Cresoline, a product of coal-tar, having the formula CgHjCHgO, vaporized 
in the nursery by a flame underneath, also has its advocates. 

All the remedies mentioned above have apparently been sufficiently 
employed to justify the belief that when judiciously employed they diminish 
the severity and duration of the paroxysmal stage of pertussis. Additional 
observations are required in order to determine the comparative efficiency of 
these agenls. 

Since the paroxysms are likely to be more severe at night, and the patient 
consequently is deprived of the required sleep, a medicine is needed which 
will procure some hours of rest and thereby diminish the number of parox- 
ysms. For this purpose the hydrate of chloral is especially useful, given in 
doses of two to five grains according to the age, and perhaps repeated. It 
does not seem to me that chloral exerts any marked influence upon the 
cough ; it appears to be useful chiefly in the manner stated — to wit, by pro- 
curing prolonged sleep. 

One of the chief dangers from pertussis we have seen to be the occur- 
rence of passive congestion of organs, especially of the brain, with the 
liability to hemorrhages, serous eff'usion, and eclampsia. This is in great 
part prevented by the action of the medicines mentioned above, which 
diminish the severity of the cough or its frequency. But when there are 
great and frequent congestions of the nervous centres, producing eclampsia 
or premonitions of eclampsia, the use of one of the bromine compounds is 
indicated for its prompt and decided action in averting the danger. Even 
if the symptoms be not urgent, its tranquillizing eff'ect, and especially its 
prompt action in diminishing reflex irritability, render it one of the most 
useful agents in pertussis. If there be sudden twitching of the muscles, 
marked stupor, headache or fretfulness, or adduction of the thumbs across 
the palms of the hands during the cough, I never fail to give the bromide 
of potassium in sufficiently large and frequent doses ; and now eclampsia 
occurs much more rarely in a case which I treat from the commencement 
than in former years. 

The complications of pertussis require prompt treatment. Whenever 
the child feels ill between the paroxysms, he should be carefully examined, 
and some complication will probably be found which requires treatment. If 
the bronchitis have increased so as to become a complication or pneumonia 
have arisen, the whole chest should be covered with a light flaxseed poultice 
containing one-sixteenth part of mustard, while quinine and ammonia with 
alcoholic stimulants are given at regular intervals. Cerebral accidents are 
best arrested by the warm foot-bath, cold to the head, and by the bromide 
and chloral. 

Diphtheria not infrequently supervenes as a complication in a locality 
where it is endemic or epidemic, and if mild it is often overlooked. Recently 
I have seen a case in which diphtheria complicating pertussis had continued 
four days, without being recognized by the attending physician, the symp- 
toms being attributed to other causes. The diphtheritic patch in these cases 

1 Omaha Clinic, 1888. ^ Asdepiad, 1883. 



ETIOL G Y—IXCUBA TION. 445 

appears upon tlie well-known sore under the tongue, in addition to its occur- 
rence upon other parts. The secondary form of diphtheria requires the same 
treatment as the primar}' form. 

Hauke in 1862 published experiments which showed that both carbonic 
acid and ammoniacal v^apors when inhaled increase the cough, while the 
inhalation of oxygen produced no cough and was agreeable to the patient. 
Hence children in close and crowded apartments suffer most severely from 
pertussis, and those who are taken to parks or the country, where vegetation 
absorbs the carbonic acid, not only obtain benefit from the general invigor- 
ating influence, but also as regards the cough. The fact that fresh and pure 
air benefits the cough has indeed long been known, and has influenced practice, 
for patients are almost universally allowed to be much of the time in the 
open air and are taken to the parks and upon excursions. Nevertheless, cau- 
tion is this regard is required, for exposure in wet weather or to sudden 
changes of temperature is very likely to develop bronchitis or pneumonia. 

Fropliylaxis. — Pertussis is very contagious, and it appears to be, in nearly 
all instances, if not in all, contracted by inhaling the breath of the patient. 
I have never observed a case in which it seemed to be communicated through 
a third person, and it is not, I think, usually contracted by children living in 
the same house if there be no personal contact. There is not, therefore, that 
urgent need of personal disinfection and of caution on the part of the phy- 
sician and nurse in their subsequent intercourse with healthy children, as in 
the case of the eruptive fevers. 



CHAPTER IX. 

MUMPS. 

Synonyms. — Parotitis^ Parotiditis. — Mumps is a constitutional or blood 
disease with local manifestations. It occurs chiefly in childhood, youth, and 
early manhood, cases being rare in infancy and old age. Its chief character- 
istic, by which it is readily recognized, is inflammation of the salivary glands, 
causing swelling and tenderness. 

Etiology. — This disease is highly contagious, and it commonly occurs as 
an epidemic. It is usually communicated through the air, which is tainted 
by the breath or by exhalations of a patient, but cases are recorded in which 
it seems to have been communicated by a third person or by infected articles. 
Thus Roth relates a case in which it appears to have been communicated by 
a physician, and another case in which it was attributed to the use of bedding 
in which a patient with mumps had slept (Bosf. JI. and S. Jovr., 1887). 

Mumps is probably a microbic disease, but the nature of the microbe has 
not been clearly ascertained. The investigations of Ollivier are confirmatory 
of those of Capelan and Charin on the occurrence of peculiarly-shaped 
micrococci in the blood and urine of patients with mumps (Haldemann, in 
the Join\ Am. Med. A.^soc. 1887). Pasteur found in the blood in mumps 
rod-shaped bacteria one millimetre broad and two millimetres long, but 
attempts to inoculate animals were fruitless (Annual of Jled. Sci.. vol. i., 
1889). 

Incubation. — Dr. Dukes states that the incubative period appeared to be 
from sixteen to twenty days in 32, and perhaps 34. of 42 cases. Henoch 
believes that the incubative period is usually about fourteen days. Goodhart 



446 MUMPS. 

relates a case which occurred fourteen days after exposure, and in two others 
the incubation appeared to be twenty-one days. Ringer says that the incu- 
bative period varies from eight to twenty-two days. Flint says that the incu- 
bation varies from ten to eighteen days. Bristowe states that the average is 
about fourteen days ; and his opinion, I think, is correct. 

Symptoms. — Mumps begins with languor and fever, the temperature in 
some cases rising to 103°, and if the fever be considerable, headache and 
vomiting are common. In a few hours, usually as early as the first visit of 
the physician, the patient complains of pain and tenderness in the depression 
below one ear and posterior to the ramus of the jaw. Notwithstanding the 
fever, the features are often pallid. Along with the pain and tenderness, 
swelling begins in the site of the parotid gland on one side, and more fre- 
quently, it is said, on the left than right. In most instances the swelling 
soon begins upon the opposite side, so that the disease is bilateral. Excep- 
tionally, it begins on the two sides simultaneously. Rarely only one side is 
aifected. The swelling gradually increases ; it fills the depression under the 
ear, extends forward and upward upon the cheek, and downward to a greater 
or less extent upon the neck. It reaches its maximum from the third to the 
sixth day. The most prominent point at this time is immediately underneath 
the lobule of the ear, which is pressed outward by the swelling of the gland. 
The tumor yields on pressure, but is elastic and tense, and the fulness 
immediately returns when the pressure is removed. The skin covering it 
preserves its normal appearance or it presents a faint blush. The fever, more 
or less intense, does not usually continue more than two to four days, but 
occasionally it remains longer. The pressure which movements of the jaw 
and of the pharyngeal muscles produce on the gland renders mastication, 
swallowing, and even speech, painful and difficult. The submaxillary glands, 
and also the sublingual, are occasionally involved, so that the features are 
greatly disfigured by the swelling. The swelling is at its maximum between 
the third and sixth days, after which it begins to decline, and between the 
tenth and twelfth days it has entirely disappeared. 

Occasionally, during an epidemic of mumps we observe cases in which 
the parotids are but slightly or not at all affected, and the chief manifesta- 
tions of the disease are in the submaxillary glands, which undergo the cha- 
racteristic inflammatory changes. Rarely the tonsils are also tumefied. Free 
perspiration occurs in certain patients at the commencement of convalescence. 

Anatomical Characters. — The opinion expressed by Virchow has been 
generally accepted, that inflammation of the gland-ducts occurs, with conse- 
quent oedema of the connective tissue. The oedema extends also to the con- 
nective tissue adjacent to the gland. 

Complications ; Sequels. — The swelling of the salivary glands some- 
times suddenly abates, and in the male the testicles and epididymis, and in 
the female the mammary glands or ovaries, are involved, with sometimes more 
or less oedema of the labia majora. Occasionally these inflammations, which 
are less frequent in young children than in those nearer the age of puberty, 
when the sexual organs are becoming more developed, occur without subsid 
ence of the parotid swelling. They cause considerable increase in the fever 
and constitutional disturbance, but with proper treatment decline in six or 
eight days, pursuing the same course as the parotid inflammation. Some- 
times repellant applications to the neck appear to produce the metastasis, as 
in the following case: On March 19, 1877, I was requested to see a young 
gentleman of eighteen years. He had been well till March 14th, when he 
complained of pain below his ears, and his mother applied a towel wrung out 
of cold water around his neck. On the following day slight swelling was 
observed under the angle of the lower jaw on the right side (submaxillary 



DIA GNOSIS— TREA TMEXT. 447 

gland), and tbe cold application was continued. On tlie ITtli the swelling 
had disappeared, but the fever and headache had greatly increased, so that 
he was compelled to lie in bed. On the 19th, at my first visit, he had such 
violent headache and was so intolerant of light and noise that I greatly feared 
that he had acute encephalitis. All swelling under the ears was gone ; the 
left testicle was tender and beginning to swell ; axillary temperature 102°. 
The cold cloths were removed from the neck and applied to the head, and 
potass, bromid., gr. xxv, administered every third hour. 20th. Axillary 
temperature 104° ; symptoms unabated and alarming. Ordered six leeches 
to be applied upon the temples and left groin, and a purgative ; and two 
drops of the tincture of aconite to be given with each dose of the bromide. 
21st. Temperature 103°. States that numbness and a pricking sensation 
which he had felt in bath legs during the last forty-eight hours had ceased 
(possibly from the aconite). 23d. Is convalescent; has no return of the 
swelling under the ears and the orchitis has abated. 

Several writers mention the fact that in rare instances orchitis precedes 
the parotiditis. Thus, Eustace Smith mentions a case in which the orchitis 
preceded by sixteen hours the symptoms referable to the salivary glands. 
The complications alluded to which involve the sexual organs occur more 
frequently at puberty or in youth than in childhood. 

It is said that deafness sometimes occurs during mumps, due to extension 
of inflammation along the Eustachian tube to the middle ear, and if the treat- 
ment proper for otitis media be employed, this form of deafness abates, 
Dalby mentions another form of deafness which comes on suddenly, and is 
supposed to be due to injury of the auditory nerve, since no appreciable lesion 
is observed of the auditory apparatus. The impairment of hearing in this 
form of deafness is likely to be permanent. 

Diagnosis. — If the physician have seen but few cases of mumps, there 
is danger that he may mistake the swelling for an inflamed cervical gland, or 
vice versa ; but an inflamed cervical gland presents to the finger a hardness 
almost like that of cartilage, and it is circumscribed or round, and does not 
invest the ear. These characteristics contrast with the elasticity, seat, and 
shape of the parotid swelling, which extends forward upon the cheek and 
surrounds and elevates the lobule of the ear. Tumefaction resulting 
from diphtheritic or any other form of faucial inflammation, or from peri- 
ostitis affecting the root of the posterior molar, may be detected by exam- 
ining the fauces and interior of the mouth. Inflammation of the parotid 
sometimes occurs in debilitated states of the system, as in or after severe 
typhoid fever, scarlet fever, measles, etc. Occurring under such circum- 
stances, the gland usually suppurates. The differential diagnosis between 
this form of parotiditis and mumps can be made by the history of the case, 
because mumps rarely occurs as a complication of another disease and does 
not cause suppuration. 

Prognosis. — The result as regards life is favorable. The orchitis, if 
bilateral, sometimes destroys the virility of the individual. Permanent impair- 
ment of hearing may also occur as stated above. 

Treatment. — This is simple. In ordinary cases it suffices to cover the 
swelling with oakum or carded wool. If the tenderness or pain be consider- 
able, the gland should be covered with spongiopilin soaked in water, and 
gently rubbed with tincture of belladonna and glycerin in equal parts. If 
the patient have severe headache, with high temperature, more active meas- 
ures are required, especially if delirium be also present. Saline laxatives 
should be given, a warm general bath or mustard foot-bath employed, and 
antipyrine with one of the bromides prescribed. The following prescription 
will be useful for a child of ten vears : 



448 MUMPS. 

R. Antipyrine, 3J ; 

Potas. bromidi, 3;iij. Misce. 

Divid. in chart No. xv. Give one powder in a wineglassful of water every three or 
four hours until the fever abates. 

Dr. Dukes states that rise of temperature is a premonitory warning of a 
complication, especially of orchitis in the male, and the early application of a 
poultice diminishes its severity. If a complication occur, fomentations should 
be constantly applied over the inflamed part, and phenacetin or antipyrine 
given at regular intervals to reduce the fever. 



SECTIOi^ III. 

OTHER GENERAL DISEASES. 



CHAPTER I 



INTERMITTENT FEVER. 

This is a constitutional malady produced by a miasm which emanates 
from the soil. I have notes of 36 cases of this disease occurring under the 
age of three and a half years. Several of these patients were treated in 
private practice, and the rest in institutions with which I have been con- 
nected. In children above the age of three and a half ^'■ears intermittent 
fever differs but little from that of the adult, while in those under this age 
it presents certain peculiarities. Of the 36 cases which I have observed, 19 
had the quotidian form, 10 the tertian, 2 the tertian becoming afterward 
quotidian, 1 the quotidian becoming afterward tertian, while in the remain- 
ing 4 cases the form of the disease is not stated. In quotidian ague the 
malaria has been supposed to act more powerfully on the system or the sys- 
tem is more susceptible to its influence than in the tertian form, and hence 
the fact that the quotidian is the prevailing type of ague in tropical regions, 
where vegetation is luxuriant, marshes extensive, and the heat intense. 
According to this theory, the feeble resisting power in the system of the 
infant explains the fact that it has quotidian more frequently than tertian 
intermittent, although the latter is much more common in the adult in this 
climate. 

Facts demonstrate that infants sometimes receive intermittent fever from 
their mothers. If mothers during gestation have malarious cachexia, their 
infants, whether born at full time or, as often happens, prematurely, are apt 
to be small, thin, and feeble, and occasionally they have soon after birth dis- 
tinct paroxysms of the ague. Dr. Stokes related the case of a pregnant 
woman with ague who believed that she noticed periodical tremors of her 
foetus, but I suspect that she was mistaken as regards the cause, for the 
paroxysm of intermittent in young children is not ordinarily accompanied by 
tremors. 

The youngest infant in my practice who apparently derived the ague from 
its mother, and probably through the foetal circulation, had the following his- 
tory : Its mother had occasional attacks of tertian intermittent during the 
two years preceding her confinement, and her baby when one week old was 
observed to have the same disease, occurring also each second day, the cold- 
ness and blueness in the first stage of the paroxysm lasting from half an 
hour to one hour. 

29 449 



450 INTERMITTENT FEVER. 

It is not fully ascertained whether a nursing infant may contract inter- 
mittent fever by lactation, but if it be admitted that it is sometimes com- 
municated to the foetus through the maternal circulation, it does not seem 
improbable that the specific principle occasionally enters the milk as well as 
other secretions. I have frequently remarked the presence of the disease in 
nursing infants whose mothers were affected, and in one instance an infant at 
the breast, whose mother had the ague, having contracted it in a suburban 
village, but now living in a non-malarious part of the city, presented evident 
symptoms of the disease. Similar observations by Frank, Burdel, and others 
do not indeed fully prove the communicability of intermittent fever by lac- 
tation, but render it highly probable. 

The period of incubation in the infant varies greatly, as in the adult. 
When the malaria is concentrated and unusually active or the condition of 
system is favorable for its reception, the disease may commence soon after 
exposure. Thus, in tropical regions travellers exposed for a single night 
have been known to sicken within twenty-four hours, but in our cooler lati- 
tude a longer incubative period is the rule. In the infant, however, in our 
climate, intermittent fever often begins in a very short time after exposure, 
though there may be an incubative period of some weeks. The following 

have been my observations relating to this point : A. M , female, eight 

months old, remained two days on Long Island in October, 1870, and three 

days after her return to the city a quotidian commenced. P. S , male, 

eleven months old, remained three days on Long Island, and a quotidian com- 
menced four days after his return. K , nine months old, remained on 

Staten Island one week, and eleven days after his return a tertian commenced. 

G. K , aged three years, remained a day and a night on Staten Island in 

18V0 ; three weeks afterward intermittent fever commenced, preceded by a 

week of languor. A. U , female, aged two years and two months, had 

the first paroxysm of a tertian two and a half weeks after returning from a 
visit of one week in Hoboken. As there was no malaria in the portions of 
the city where these infants resided, the incubative periods are nearly 
ascertained. 

Etiology. — The cause is believed to be a microbe which exists in the 
soil and upon and near its surface. Wherever the cause exists intermittent 
fever is endemic, and for a series of years, until the character of the soil is 
changed by drainage. The morbific agent is more abundant and active at 
night than in the day-time, and in wet than in dry seasons. It ascends from 
the soil to the lower and not the higher strata of the air, so that those who 
sleep in the basement or ground-floor of a house are more frequently affected 
by the malaria than those in the upper story. Intermittent fever is never 
contracted through the breath or exhalations of a patient or through infected 
articles of clothing or furniture. It is not, therefore, contagious. 

The organism which causes malarial fever is not fully ascertained. The 
so-called ague-plant discovered by Prof. Salisbury in 1866, and the bacillus 
detected by Klebs and Tommasi Crudeli in the soil of malarial regions, which 
they supposed to be the cause of the malarial fevers, are now believed to be 
innocent organisms as regards these diseases. 

More importance attaches to the organisms discovered in the malarial blood 
by Laveran in 1861. They occur in the red blood-corpuscles and are al-so free 
in the blood. Their average size is about one-third that of the red blood- 
corpuscles, but some are smaller and others larger than this. Some of them 
contain dark -brown granules, and others are without pigment. In fresh blood 
these bodies exhibit amoeboid movements, changing their forms like the white 
blood-corpuscles. That they are living organisms we infer from their move- 
ments. They have been found nowhere except in the blood of malarial 



SY3IPT0MS. 451 

patients, and chiefly during the paroxysms. Marchiafava and Celli state 
that they have produced malarial fever in a person previously healthy by 
injecting blood containing these organisms into a vein; and they found the 
same organisms in his blood after the fever had appeared. They believe that 
these bodies are parasites having amoeboid movements, and that they pene- 
trate the red blood-corpuscles, which they destroy in proportion to the degree 
of encroachment, and produce in them the characteristic malarial pigment. 
Osier also describes at length the various forms which this organism assumes, 
the crescentic form appearing especially in chronic cases. He states that 
quinine is a specific against these organisms, causing them to disappear f Brif. 
JJed. Jour., 1887). Councilman of Baltimore examined this organism, and 
noticed its highly polymorphic nature, presenting globular, crescentic, rosette, 
and flagellate forms. He states that the administration of fifteen grains of 
quinine daily for three or four days causes the almost total disappearance of 
the organism. But the crescentic organism of malarial cachexia is not mate- 
rially aiFected by the quinine (Therapeutic Gaz., 1887). Subsequent investi- 
gations have therefore tended to substantiate the opinion of Laveran, that 
malaria is caused by an organism having amoeboid movements which pene- 
trates and destroys the red blood-corpuscles. 

Whatever may be the nature of the malarial poison, it often clings 
tenaciously to the system, and is probably reproduced in it even under 
circumstances favorable for its elimination. Thus, at one of my cliniques 
at Bellevue Hospital Medical College in 1871, a child ten years old was pre- 
sented who had had every year for seven years attacks of intermittent fever. 
The disease was contracted at the age of three years in Harlem, and the sub- 
sequent residence of the family had been in a part of the city where there 
was no malaria. 

Symptoms. — In infancy, and especially prior to the age of eighteen 
months, the symptoms differ in certain respects from those which charac- 
terize the malady in the adult, and are universally known. In childhood the 
symptoms are similar to those in the adult, and need not therefore be described 
in this connection. 

In the infant the type, as we have seen, is quotidian, with now and then a 
tertian. Advancing beyond the age of eighteen months, we meet more and 
more cases of the tertian type, and in childhood the tertian is the common 
form. I have known the quotidian in the infant, when cured, to reappear 
a few weeks later as a tertian ; but ordinarilj" it remains quotidian, unless 
the patient have reached the age at which the tertian type predominates. 

The paroxysm in the young infant presents three stages, as in the adult, 
but while the second, or febrile, is well marked, the first and third are much 
less pronounced. The patient does not shake (exceptionally one does even 
within the first year) in the first stage, but a slight tremor may or may not 
be observed. The countenance presents a sunken appearance, the lips and 
fingers are livid, while portions of the surface not livid are pallid, with the 
goose-flesh appearance, which is, however, less marked than in children of a 
more advanced age. The blood leaves the surface, which consequently 
shrinks, while it accumulates in the veins and internal organs ; the pulse is 
feeble and readily compressed ; the surface grows cool from the diminished 
supply of blood, but the breath is warm, and the internal temperature, so 
far from being reduced, is elevated two or three degrees. The parents may 
be alarmed at the sudden sinking of the vital powers and seek medical 
advice, but in other instances the first stage is so slight that it passes unper- 
ceived till they have been taught to watch for it, and the second stage first 
attracts attention. 

In the second or febrile stage, which immediately succeeds, the pulse 



452 INTERMITTENT FEVER. 

becomes full and rapid, 120 to 130 or 140 beats per minute, and the exter- 
nal as well as internal temperature is elevated as in few other diseases 
(104°-108°). The face is flushed, surface dry, and head painful, as evinced 
by the features. This stage lasts about two or three to six or eight hours. 
The third stage, or that of perspiration, succeeds, which terminates the suf- 
fering of the patient till the following paroxysm. In infancy the perspi- 
ration is not abundant, and in the first half of this period is nearly absent. 
In the interval of the paroxysm the patient appears well, except a degree of 
languor. 

In 24 of the cases of infantile intermittent which I have treated my 
notes describe the character of the paroxysms. In 16 of these there was 
no chill or trembling in the first stage, but blueness and coolness of the 
extremities and features and sudden prostration. This stage lasted from 
ten minutes to one hour. In the 8 remaining cases the infants were observed 
to tremble or shake as in adult cases. The perspiration of the third stage 
was in nearly all cases, when observed, slight and of short duration, but in 
some it was not observed. 

During the cold stage passive congestion of the internal organs occurs to 
a greater or less extent, but the circulation is equalized during the reaction 
of the second stage. The spleen, whose capsule is distensible, soon enlarges 
in many patients in consequence of the frequent and great congestions, con- 
stituting the "ague cake." This enlargement is more common in children 
than adults. Since my attention has been particularly directed to this sub- 
ject, I have been able to feel the enlarged spleen, by examination through 
the abdominal walls, in probably one-third of the cases under the age of ten 
years. This organ returns to the normal size after the ague is cured. From 
the intimate relation of the spleen to the composition of the blood, it is evi- 
dent that the character of this fluid must be affected if intermittent fever be 
protracted. The blood becomes more and more impoverished and a state of 
decided hydrsemia supervenes. A few weeks' continuance of the ague suf- 
fices to produce decided pallor of the features and surface generally, and as 
all watery blood is prone to transudation, such patients not infrequently 
present more or less oedema of the face, ankles, and other parts. Sometimes 
also, especially under unfavorable hygienic circumstances, purpuric spots 
(purpura hasmorrhagica) appear under the skin, afl"ording additional proof of 
the change which the blood has undergone. 

In long-continued cases of malarial disease in the adult waxy degenera- 
tion of organs is apt to occur, as well as melanasmia. Pigment-cells, flakes, 
and particles appear in the blood, the coats of the minute arteries, and in 
various organs, as spleen, liver, etc. In the child these results are more 
rare. 

Intermittent fever in children, if proper remedial measures are employed 
at an early period, is ordinarily not dangerous, and is quite amenable to 
treatment ; but that comparatively infrequent and fatal form of it desig- 
nated the pernicious occurs more frequently in children than adults. In 
New York City, where the type of malarial diseases is mild, I have never 
met a case of pernicious intermittent in the adult, but I can recall to mind 
such cases in children, two of them fatal. This form of the fever occurs in 
a smaller proportionate number of cases in infancy than in childhood, proba- 
bly because the cold stage is less pronounced. In the pernicious ague the 
system is overpowered — it does not react in a degree commensurate with the 
intensity of the disease. The patient enters the cold stage, becomes stupid, 
and, if not relieved by prompt and efficient measures, passes into fatal coma. 
A type of the disease, therefore, which would not be pernicious in a robust 
individual may be such in one of a broken-down constitution and feeble 



TREATMENT. 453 

reactive power. In most cases occurring in children the coma is preceded 
by eclampsia, which is apt to be general and protracted. 

Eclampsia" increases the passive congestion of the cerebro-spinal axis 
already present in this stage, and if not speedily relieved may end in trans- 
udation of serum over the surface of the brain, and perhaps meningeal 
apoplexy, causing fatal coma. This has occurred twice in my practice. 

Sometimes in young children the diagnosis of intermittent fever is doubt- 
ful, either because the disease has not continued sufficiently long or there 
has not been the characteristic paroxysm. The patient may be feverish and 
fretful, with anorexia and evidences of headache, but without the usual dis- 
tinctive symptoms. I have sometimes in such cases been able to establish 
the diagnosis by detecting enlargement of the spleen. In examining for the 
" ague cake " the child must lie quietly on its back, and the fingers, placed 
midway between the epigastrium and umbilicus, be carried gently but with 
firm pressure outward in the direction of the spleen, when the anterior edge 
of this organ will be felt if it be enlarged. It is impossible to make the 
examination when the child cries, on account of the contraction of the 
abdominal muscles. 

Treatment. — It is evident that no time should be lost in applying appro- 
priate remedies in a case of infantile ague, for, although the first paroxysm 
may be mild, the next may be more severe and attended with danger. 
Moreover, the sooner the disease is cured the less liable it seems to be 
to return. Therefore we prescribe at once the sulphate of quinia or cin- 
chona, one and a half grains of the latter producing the effect of about 
one grain of the former. Our experience in the children's class in the Out- 
door Department has been chiefly with the sulphate of cinchona on account 
of its cheapness, and there has yet been no case of ague which it has failed 
to control. A recent writer has published statistics showing his success in 
curing intermittent fever by this agent, but nothing in therapeutics is more 
easy than to cure this disease in our climate by either of the sulphates men- 
tioned. The chief dif&culty consists in preventing a return. To an infant 
of two years I prescribe one grain of sulphate of quinia or the equivalent of 
sulphate of cinchona three times daily, till all symptoms of the ague have 
disappeared ; then twice a day during the subsequent week, and afterward 
once a day for some days, and finally twice or thrice a week. It is only by 
the protracted use of the drug in occasional doses that the return of the 
intermittent can be prevented. 

It is important in administering these sulphates to infants to employ a 
vehicle which will, so far as possible, disguise the bitterness. The vehicle 
which I prefer for their administration is the elixir adjuvans, elixir tarax, 
comp., or, better still, the syrupus yerbae santse comp. The following formula 
is for a child of three years : 

R. Quiniae snlphat., gr. xvj ; 

Syr. pruni virginiani, 
Syr. yerb?e santse comp., da. 5J. Misce. 

The following is also a good formula : 

R. Qniniae sulphat., gr. xvj 

Syr. yerbpe santse comp., 

One teaspoonful three to five times daily. The first dose should be given 
immediately after the fever abates. In this climate two or three days suffice 
to cure the disease, after which, by daily but gradually diminished use of 
medicine in the manner stated above, the return of the malady is prevented. 



454 REMITTENT FEVER. 

Protracted cases attended by ansemia require the use of iron in addition to 
the remedy which is designed to control the disease. 

For children with irritable stomachs, who cannot retain the salts of quinine 
which are ordinarily prescribed, the tannate may be employed in powder or 
lozenges with chocolate ; but in order to produce the same effect the dose 
must be two and a half times greater than that of the sulphate or muriate. 
The protracted cachexia which follows an attack of malarial fever is best 
treated in children, as it is in adults, by arsenic, especially the liquor potassae 
arsenit, and iron. Quinine is much less efficient in curing this cachexia than 
these agents. 



CHAPTER II. 

EEMITTENT FEVER. 

If a physician were to consult the standard treatises on diseases of chil- 
dren in order to ascertain the nature of remittent fever, he would rise from 
the perusal with no clear idea of it. One tells us that the remittent fever 
of children is identical with typhoid fever of adults ; another, that it is a 
gastro-intestinal inflammation ; and, finally, Hillier believes that there is 
properly no such disease, and that the term should be dropped from the 
nosology of diseases of children. There is, however, a remittent fever of 
children as well as adults, and much of the confusion which exists in refer- 
ence to it arises from the fact that writers have not kept in view what con- 
stitutes a fever. 

Febrile action which has a local cause is not an essential fever, and should 
not be described as such. It happens that in children a symptomatic remit- 
tent fever arises from a variety of local causes, as dentition, intestinal worms, 
subacute gastro-intestinal inflammation, etc. But all such cases should be 
excluded from our consideration of remittent fever as clearly as we distin- 
guish the continued fever of pneumonia or bronchitis from that of typhus or 
typhoid. 

There is an essential remittent fever of children due to malaria. The 
same conditions which produce intermittent fever do, in a certain proportion 
of cases, produce a fever which does not intermit, but continues with more 
or less pronounced exacerbations a certain number of days, when it ceases or 
becomes intermittent. Those who practise in malarious localities notice a 
larger proportion of cases of remittent fever among children than adults, 
because their constitutions are less able to resist the malarial poison, so that 
an exposure which in an adult would produce milder disease — to wit, a ter- 
tian ague — frequently causes a quotidian or remittent in the child. 

In hot countries, where the malarial poison is more active and the diseases 
due to malaria more severe than in the temperate regions, cases of remittent 
fever due to the marsh miasm are more common than in the temperate 
regions. The "jungle fever" of India is a malarial remittent fever of a 
severe type. 

In my opinion, the term " remittent fever,"' if retained in nosology, 
should be restricted to those fevers of a remitting type which are due to 
marsh miasm, so that it differs from intermittent fever in the fact of a 
greater intensity and not in its essential nature. The one disease is cha- 
racterized by intervals of apyrexia, and the other by periods of a diminution, 
but not cessation, of the febrile symptoms. 



TREATMENT. 455 

In New York City, and probably in other localities in the temperate zone, 
a continued fever of a mild type not infrequently occurs in children, espe- 
cially in the spring and autumn, running a course of one to two, three, or 
even four, weeks, with in many cases a slight increase in the latter part of 
the day. Children with this fever are languid, moderately thirsty, and with- 
out appetite. They complain in the first days of headache. Their tongue is 
moderately furred. They have a slight cough, no diarrhoea, a temperature of 
101° or 102°, and many of them do not feel ill enough to go to bed, except 
at the usual hours of sleep, during the whole progress of the disease, which 
continues a variable time, from one to three weeks. This disease physicians 
of New York sometimes designate remittent, sometimes malarial, and occa- 
sionally, the severe cases, typho-malarial. I have noticed that this light 
form of fever occasionally occurs in a household or asylum in connection 
with typical cases of typhoid fever, and therefore am led to regard it as a 
mild form of this disease. Thus in a family in West Fifty-fourth street two 
children had this fever so mildly that they were every day dressed and sitting 
quietly in the room, but their aunt, a lady of about thirty years, who took 
care of them, sickened with a severe typical and protracted typhoid fever 
while she was attending them. In the Roman Catholic Orphan Asylum of 
this city typhoid fever occurred some years ago, and some of the cases were 
of the mild form described above, but two or three were fatal, and the cha- 
racteristic lesions of typhoid fever were discovered at the autopsies. There- 
fore this mild continued fever, having perhaps a slight but scarcely apprecia- 
ble morning remission, should not, in my opinion, be designated remittent, 
malarial, or typho-malarial — terms which have been applied to it — but be 
regarded as a mild typhoid fever. It seems to me that typhoid fever, like 
diphtheria, does sometimes present so mild a type in childhood that the 
patients are not confined to bed, and their sickness terminates in one or two 
weeks, instead of three or four, as stated in the books. 

Symptoms. — This disease begins with chilliness and headache, and exacer- 
bations and remissions occur each day. In severe cases the temperature 
during certain hours reaches 104° or 105°, and the exacerbation may be 
accompanied by delirium or stupor. The severe headache, restlessness, and 
jactitation show that the nervous system is profoundly involved in certain 
cases. There may be distinct remissions in the beginning, and afterward, for 
a few days, the fever be pretty uniform, when it again remits or ceases. The 
tongue is covered with a light fur. Thirst, loss of appetite, a tendency to 
constipation, and scanty, high-colored urine containing urates, are common 
symptoms. 

Diagnosis ; Prognosis. — Typhoid fever usually comes on more grad- 
ually than remittent fever, and is not attended by so great a daily variation 
in temperature. It is of more importance to make the difi'erential diagnosis 
between remittent fever and the acute local diseases, especially meningitis 
and pneumonitis ; but a careful examination of the signs and symptoms, which 
will be considered hereafter in our remarks on the local diseases, will enable 
us to make the diagnosis. The prognosis is favorable with prompt and appro- 
priate treatment. 

Treatment. — Prompt treatment by one of the salts of quinine is required. 
Formerly it was thought advisable to employ first laxative and diaphoretic 
remedies, in the belief that quinine, if administered immediately, might cause 
cerebral congestion. But since the bromides and antipyrine came into use 
no treatment preparatory to the use of quinine is required, unless a sin- 
gle laxative dose in the beginning, as by calomel or the magnesium citrate. 
Alternate doses of quinine and bromide of potassium, at intervals of two 
hours, will in a few days control the fever. The bromide will prevent any 



456 TYPHOID FEVER. 

ill effects of the quinine in producing cerebral congestion, which was formerly 
feared. In cases attended by marked pyrexia, jactitation, and delirium anti- 
pyrine should be added to the bromide. 



CHAPTER III. 
TYPHOID FEVER. 

Typhus and typhoid fevers occur in children, but the former is mild and 
infrequent, rarely occurring except when adults of the same household are 
affected. It requires little treatment besides good nursing. Typhoid fever, 
on the other hand, is not infrequent in children, and, as it presents certain 
peculiarities prior to the age of puberty, it is proper to describe it in this con- 
nection. This disease is much less common in infancy than in childhood, 
and in the first half of infancy is believed to be rare. Still, there can be no 
doubt that many cases in the first years of life are not diagnosticated, being 
mistaken for subacute and protracted entero-colitis. It is probably more 
common under the age of six years than is usually supposed, although the 
younger the child below this age the less frequent does it appear to be, while 
above the age of six years it is more and more frequent until puberty. In the 
statistics of Cadet de Gassicourt, embracing 276 children, 3 were at the age of 
two years, 7 at the age of three years, 8 at four years, 13 at five years, and 
the number gradually increased in successive years until there were 32, 41, 
and 42 cases at the ages of twelve, thirteen, and fourteen years. Farnham 
has reported a case occurring in a girl of three years whose father was at the 
time convalescing from the fever. She complained of feeling tired, and was 
listless, but fretful. Her surface was hot and face flushed in the latter part 
of the day. Her temperature on the seventh day reached 104.8°, when she 
was put to bed. The fever ceased on the sixteenth day, after which the 
temperature was subnormal for ten days. 

Causation. — Klebs in 1881 announced that he had discovered a bacillus 
in cases of typhoid fever, which he believed to be the cause of the disease, 
and which he designated the bacillus typhosus. Each bacillus contained a 
spore in its interior, and often one at its extremity from which new bacilli 
developed.^ About the same time Eberth also discovered the bacillus in the 
intestinal mucous membrane, the mesenteric glands, and spleen in typhoid 
fever, and ascertained that it differed from other bacteria in the staining. 
In 17 cases these bacilli were found in 6, and not found in 11.^ 

Gaffby announced the results of his observations and experiments with 
the bacillus typhosus. He succeeded in cultivating it in various substances. 
Upon the surface of potato, sterilized by steam, it grows abundantly, forming 
rods 0.2/7. thick and 0.6,a to 0.8/7, in length. The rods have active move- 
ment and are aerobic. 

The bacillus typhosus is constantly found at an early stage of typhoid 
fever in the spleen, mesenteric glands, Pej'^er's patches, and the solitary 
follicles. Occasionally it has been discovered in the lungs, liver, and kidneys, 
and rarely in the blood. When the symptoms pertaining to the fever begin 
to abate, the bacillus also begins to disappear, so that in the fourth week it 
sometimes cannot be discovered, and is usually less abundant than in the first 
and second weeks ; but it may be present after the fourth week. The bacilli 

1 Phila. Med. Times, Dec. 3, 1881. ^ ^,.,-^_ j/^^/^ j^^^^^ -^^^^ 26, 1881. 



CAUSATION. 



457 



occur in colonies or irregular masses. The figure represents the bacilli as 
observed in the spleen. 

The bacillus typhosus has not been discovered in any other disease than 
typhoid fever, although search has been made for it. Frankel and Sim- 
monds inoculated rabbits with it. They were sick in consequence, and in 

Fig. 29. 




those that died the spleen, the solitary follicles, Peyerian patches, and certain 
lymphatic glands were found tumefied. For the reasons stated, pathologists 
for the most part agree that this bacillus is the cause of typhoid fever, but 
from the fact that no bacilli, or but few, are found in the blood, it is not 
improbable that the fever and other prominent symptoms of the disease may 
be largely due to ptomaines which the bacilli produce. 

The bacillus typhosus is very tenacious of life. Prudden found that it 
could be cultivated after it had been frozen in ice one hundred and three days ; 
also after it had been subjected to a heat of 132.8°, and again when it had been 
alternately frozen and thawed.^ Yidal and Chantemesse, by capillary punc- 
tures of the spleen during the life of the patient, obtained the bacillus, with 
which they inoculated mice and guinea-pigs, and subsequently discovered this 
organism in their lungs and abdominal organs. They also found it in the 
placenta of a typhoid patient who aborted at the fourth month.' 

Vaughan and Novy obtained cultures of the typhoid bacillus from the 
water used by a considerable number of typhoid-fever patients, and the 
syrupy extract containing the bacillus and the ptomaines produced by it, 
injected under the skin of cats, caused 2° to 4.5° of rise in temperature. 
They have formulated the following definition of the disease : " An infectious 
disease arises when a specific pathogenic micro-organism, having gained admit- 
tance to the body, and having found the conditions favorable, grows and 
multiplies, and in so doing elaborates a chemical poison which induces its 
characteristic effects." ^ 

The discovery of the bacillus typhosus, and of its causal relation to 
typhoid fever, afi"ords important aid to our knowledge of the manner in 
which typhoid fever is produced. The theory advocated by Murchison, 



N. Y. Med. Re 



1887. 

^ Ptomaines and LeiLcoma'ines, 1888- 



Lond. Lane, 1887. 



458 TYPHOID FEVER. 

that this disease may originate de novo by exposure to filthy accumulations 
of any kind, is now known to be false. Only such substances can commu- 
nicate the disease as contain the specific bacillus, and it is obviously neces- 
sary that this bacillus should in some manner enter the system, so as to infect 
the individual. Exhalations from the most fifthy accumulations, and even 
inoculation with the most fetid material, will not cause typhoid fever unless 
the bacillus typhosus be present. But the remarkable vitality of this organ- 
ism, and its power of propagation in certain substances in common use, as 
water and milk, give rise to epidemics in localities where it happens to be 
introduced. 

Typhoid fever is seldom, and perhaps not at all, contracted by inhaling 
the breath of a patient or exhalations from his surface, but his urinary and 
fecal excreta contain the bacillus in abundance and are the most common 
source of infection. Many instances are on record of epidemics caused by 
the use of water for culinary or drinking purposes which had been in some 
manner polluted by the excreta of typhoid patients. One of the earliest 
recorded instances of this kind was observed by the late Prof. Austin Flint 
in 1843. In a village in Western New York a traveller with typhoid fever 
was cared for at the inn, and his excreta were deposited near the well which 
supplied the whole village except one family. The stranger died, and within 
a month typhoid fever occurred in all the families of the village except the 
one that obtained water from a different well. At Pierrefonds 23 persons occu- 
pied adjacent houses. The water which they used was obtained from shallow 
wells into which it had percolated through a porous soil from a neighboring 
stream. This stream received the drainage of two cesspools, one being thirty 
and the other sixty-five feet from the well, and the well was on lower ground 
than the cesspools. In August and September, 20 of the 23 persons were 
attacked with typhoid fever, and in one of the houses 4 died. The water sup- 
plying this house was examined by Chantemesse in October, and was found to 
contain the bacillus of typhoid fever in abundance. A month subsequently 
none could be found. Vienna, Angouleme, Cincinnati, and Bordeaux may be 
mentioned among the places where the occurrence of tj^phoid fever has been 
traced to pollution of the drinking water. In 1888 a severe epidemic of 
typhoid fever occurred at Iron Mountain, Michigan, and in the drinking 
water employed in families that had suffered from the disease Yaughan 
and Novy found the typhoid bacillus. Therefore, sufficient observations 
have been made to show that many epidemics of typhoid fever have been 
caused, and are still caused, by the use of polluted drinking water which con- 
tained the specific bacillus, and that when epidemics arise from this cause it 
apparently gains admittance into the system through the digestive apparatus. 
In 1871, Ballard, health ofiicer of Islington, called attention to the fact that 
the use of infected milk sometimes causes typhoid fever. He had investi- 
gated an outbreak of the disease which was apparently produced by rinsing 
milk-cans with water which was polluted by direct communication of the tank 
with drains. Since then a considerable number of epidemics have been traced 
to the use of infected milk. The milk in most of the investigated cases was 
contaminated by polluted water employed in rinsing the cans or added to the 
milk for the purpose of diluting it. Milk may also receive the typhoid bacil- 
lus from ice which contains this organism and is employed for the purpose 
of reducing the temperature or for dilution. Seitz, Wolfhiigel, and Reidel 
have shown that the typhoid bacillus grows freely in milk. Yaughan mixed 
water containing the typhoid bacillus with milk, and subsequently was able 
to obtain from the milk a poisonous extract due to the growth and activity 
of the bacillus {Med. Neios^ Jan. 28, 1888). Therefore the milk-supply 
should also be investigated on the occurrence of an epidemic. 



ANATOMICAL CHARACTERS. 459 

But typhoid fever is probably communicated by the inhalation of air 
which contains the typhoid bacillus, although, as we have seen, the disease is 
not likely to be contracted by the attendants of typhoid patients if there be 
prompt and efficient disinfection of the excreta. In New York City many 
observations show that the filthy flowing streams in the sewers are infected 
with the typhoid bacillus, and cases occur in which the fever seems to be 
due to the escape of the sewer gas into the houses. Thus, in my practice, 
in a house whose plumbing was supposed to be faultless three children who, 
so far as known, had not been exposed outside, sickened with typhoid fever. 
A thorough examination finally revealed the escape of sewer gas into the cel- 
lar in a strong current. The inference is that in such instances the tainted 
air conveys the bacillus to the lungs, and this organism enters the system 
through this organ. But it is true that the bacillus in such instances may be 
deposited from the air in the food or drink, or in the mouth or fauces, and be 
swallowed, so that the systemic infection may occur through the digestive 
system. But it suffices, so far as the employment of preventive measures is 
concerned, to know that an atmosphere infected by exhalations from filthy 
sources may communicate typhoid fever without the actual presence of a 
typhoid patient. Between 1873 and 1885, one hundred and forty-six cases of 
typhoid fever occurred in one of two barracks occupied by the Grerman artil- 
lery, while cases did not occur in the other barrack, although the water and 
food used in the two were the same. Finally, suspicion fell upon the bed- 
linen and clothing, and the discovery was made that recent patients had worn 
the clothes of men previously attacked, and even stains of dried fecal 
matter were found in their pants. Saturation of the infected articles and 
the barrack with chlorine gas followed by dry heat was now employed, and 
no more cases occurred (^Mecl. Press and Circ.., March 28, 1888). There- 
fore the typhoid bacillus gains admittance into the system not only by the 
use of infected drinking water, milk, and solid food, but also b}^ the inhala- 
tion of an infected atmosphere. 

Anatomical Characters. — Since typhoid fever is a constitutional dis- 
ease, we would expect to find early and important changes in the blood. No 
alteration, however, has been discovered in this fluid peculiar to typhoid 
fever. The amount of fibrin is diminished, as in most of the essential fevers, 
and its coagulation is feeble, forming, when the blood stands, soft, small, and 
dark clots. When the fever has continued for some time a state of anaemia 
more or less decided supervenes in which the amount of albumen and blood- 
corpuscles is diminished. Although there are often decided symptoms refer- 
able to the nervous system, no constant changes have been discovered in the 
brain or spinal cord. The changes observed in them when death has occurred 
in the course of typhoid fever have been for the most part due to other 
causes. It is difl"erent with the respiratory system. After the first week of 
typhoid fever mild bronchitis is almost as constant as inflammation of the 
fauces in scarlet fever, and accordingly we find in fatal cases redness and 
thickening of the bronchial mucous membrane, which is covered with a viscid 
and ordinarily scanty secretion. Hypostatic congestion of the lungs, with 
more or less oedema, and in severe and enfeebled cases hypostatic pneumo- 
nia, are not uncommon. In the bronchitis and state of feebleness we have 
the causes of pulmonary collapse, and this lesion is not infrequent over 
limited portions of the lungs, especially if the bronchitis aff*ect the smaller 
tubes. 

The lesions occurring in the digestive system are important. The pharynx 
is normal or slightly afl"ected. The mucous membrane of the oesophagus 
and stomach is sometimes normal or nearly so, and in other cases hypernemic. 
It is said that ulcers have been occasionally observed in the cardiac end of 



460 TYPHOID FEVER. 

the oesophagus. The mucous membrane of the small intestine is more or 
less injected, and at an early period, even by the second or third day, the 
patches of Peyer, solitary glands, and at the same time the mesenteric, 
begin to enlarge. I have made microscopic examination of these glands in 
typhoid fever of the adult, and have found a considerable increase of the 
small round granular cells of which they are composed. It appears, there- 
fore, that the enlargement is due mainly to hyperplasia of the cellular ele- 
ments of the glands, though there is probably infiltration to a certain extent 
of inflammatory products between the cells. The mucous membrane over 
the glands undergoes inflammatory thickening and softening. In the adult 
sloughing of this membrane is frequent, with the disintegration of the glands 
and their elimination into the intestines, producing ulcers, small and circular, 
corresponding with the site of the solitary glands, large and oval or irregular, 
corresponding with the site of Peyer's patches. Disintegration of these 
glands and the formation of ulcers are less frequent in children than in 
adults. In the adult who recovers the mesenteric glands and the solitary and 
agminate which are not destroyed return to their normal state by fatty degen- 
eration, liquefaction, and absorption of the redundant cells. In the child this 
is the common result, instead of sloughing and disintegration, as regards both 
the solitary and agminate glands, and uniform result as regards the mesen- 
teric, and I may add bronchial glands, which are also in a state of hyperplasia. 
The absence of ulceration or its slight extent afl'ords explanation of the fact 
that intestinal perforation is very rare in children. The inflammatory changes 
described above pertain chiefly to the ileum. The duodenum and jejunum 
present their normal appearance or are moderately hyperaemic in places and 
their follicles swollen. 

The spleen gradually enlarges, often to twice the normal size, has a dark- 
red color, and is softened. Enlargement of the spleen possesses great diag- 
nostic value in those cases in which the diagnosis is obscure. For while very 
similar intestinal lesions may occur in chronic entero-colitis, the coexistence 
of these lesions with the splenic enlargement and softening shows the con- 
stitutional nature of the malady. The liver usually presents its normal 
appearance, or it may be pale in consequence of the anaemia, or, on the other 
hand, it may be hyperaemic. Microscopic examination sometimes reveals a 
granular state of the hepatic cells with indistinct nuclei. 

In cases which are severe and which present a decidedly adynamic type 
the muscles become soft and flabby, the action of the heart is feeble, and 
more or less passive congestion of the viscera results. In such cases con- 
gestion of the kidneys and albuminuria are not infrequent. Parenchymatous 
degeneration of the kidneys occasionally occurs, the epithelium becoming 
granular, the cells indistinct, and their nuclei invisible. Liebermeister states 
that he has frequently noted the absence of albuminuria during the fever 
when the autopsy showed marked degenerative changes in the kidneys. 
Inflammation of the endocardium and pericardium is rare, but the myo- 
cardium exhibits structural changes in severe cases. Atrophy and fatty 
degeneration of its muscular fibres sometimes occur, which may lead to the 
formation of clots in the cavities of the heart, and consequent emboli in 
other organs. Hofl'mann demonstrated the occurrence of fatty degenera- 
tion of the minute arteries in various organs in prolonged cases of typhoid 
fever, and degenerative changes have also been observed in the voluntary 
muscles. 

Pathology. — Recent investigations relating to the acute infectious dis- 
eases of childhood render it probable that as regards most, if not all, of them 
systemic infection occurs through ptomaines or poisonous chemical agents 
which are produced by the action of the microbes which are the specific 



SYMPTOMS. 461 

principles. This is believed to be true as regards typhoid fever. In 1885, 
Brieger obtained a ptomaine from cultures of the typhoid bacillus which, inocu- 
lated in guinea-pigs, caused salivation, hurried breathing, dilated pupils, diar- 
rhoea, paralysis, and death within one to two days.^ From such observa- 
tions and experiments the theory has arisen that the symptoms which cha- 
racterize typhoid fever are mainly due, not directly to the action of the 
bacillus, but to a ptomaine or ptomaines created by the bacillus and 
absorbed into the system. This theory also receives support from the 
observations and experiments of Hoflfa, Sirotirvin, Beaumer and Peiper, 
and others. 

Incubative Period. — As in scarlet fever and diphtheria, the incubative 
period in typhoid fever varies. In three cases detailed by Griesinger the 
fever began twenty-four hours after exposure. In a school at Clapham, 20 
out of 22 boys sickened, according to Murchison, within four days after 
exposure. Authenticated cases of a longer incubative period are on record, 
so that Murchison believed that it is commonly about two weeks, and 
William Budd that it is in most instances from ten to fourteen days, but 
cases have occurred in which it seemed to be as long as twenty-eight 
days.^ 

Symptoms. — Typhoid fever has a prodromic stage of a few days, some- 
times of a week or more, in which the child appears languid, indisposed to 
play, and has little appetite, but complains of no pain unless occasional 
slight headache, and has no symptoms which would lead the friends, or even 
physicians, to suspect the nature of the disease which impends. By and 
by a slight fever occurs. 

In exceptional instances typhoid fever begins with a chill, followed by 
pronounced fever. It occurred in 3 of the 14 cases observed by Dr. Jacobi 
in Bellevue Hospital. This was a larger proportion of cases with such com- 
mencement than I observed in the epidemic of 1882 or have since observed, 
but the cases in Bellevue seem to have been uuusually severe, since 5 of the 
14 died. 

The fever, which gradually becomes more pronounced, remits, but does 
not cease in the morning, and it has evening exacerbations. After the first 
week of fever the remissions are less marked, but the fever is not uniform 
at any period in its course. Hence some of the writers on diseases of children 
continue to designate typhoid fever of children remittent fever, fully aware 
of its identity with typhoid fever of the adult. As the case advances the 
appetite fails, all solid food being refused, and liquid food being taken more 
from thirst than hunger. The tongue in the first week, and in some patients 
throughout the course of the disease, is covered with a light moist fur, while 
in others having a graver type of the fever the tongue after the first week is 
dry and brown. During the prodromic period and in the first week the 
bowels act regularly or are slightly relaxed, and they are readily affected by 
purgative medicines. After the first week there is in some children a tend- 
ency to diarrhoea, which requires now and then the use of astringents, the 
stools being watery and brown or dark yellow. Diarrhoea is less frequent in 
children than in adults, and in some children it does not occur during the 
entire sickness. The abdominal walls are seldom retracted, but prominent, 
especially after the first week, in consequence of meteorism, which is present 
in children as well as adults. Sometimes there is apparent tenderness when 
pressure is made over the right iliac region, but this must not be confounded 
with hypersesthesia, which is common in the commencement of febrile diseases 

^ L. Brieger, Veber Ptomaine, Berlin, 1885-86. 

'^ See article " Typhoid Fever," American System of Practical Medicine ; Philada., 1885,. 
Lea Bros. 



462 TYPHOID FEVER. 

in children, and which is observed especially upon the abdomen, chest, and 
inner part of the thighs. 

The respiration in the first week is slightly accelerated, as it is in all 
febrile diseases. In the second week, and subsequently when bronchitis is 
developed, the respiration is ordinarily more accelerated, though not in a 
marked degree, unless in those exceptional instances in which there is an 
abundant collection of mucus in the smaller bronchial tubes. A cough is 
often present, dependent on the bronchitis, and varying in character accord- 
ing to the degree and stage of the inflammation. In the first days of the 
fever it is infrequent or lacking ; at a later stage it is more frequent and not 
so dry, though in cases of ordinary severity the amount of expectoration is 
inconsiderable. Hypostatic congestion, oedema, hypostatic pneumonia, spleni- 
zation or thickening of the alveolar walls, and collapse, which not infre- 
quently occur in the advanced disease, increase more or less the frequency 
of the respiration and the cough and modify the physical signs. 

The pulse in the first week, in ordinary cases, is from 100 to 110 or 115. 
It gradually becomes more accelerated, numbering in the second week 123 or 
more; in grave cases even 160. The more frequent the pulse, the greater 
the danger and more unfavorable the prognosis. During the exacerbations 
the number of pulsations per minute is fifteen or twenty more than in the 
remissions. The change in temperature corresponds with that of the pulse, 
being from 1° to 2° higher in the exacerbation than remission. The extremes 
of temperature in cases of ordinary severity are about 101° to 104°. A tem- 
perature above 105° shows a grave, perhaps a fatal, type of the disease or 
else a serious complication. 

There is great variation as regards the symptoms referable to the nervous 
system. Headache is common in the prodromic and initial stages, after which 
it ceases- A few are delirious even from an early period, screaming loudly 
or muttering incoherently, but the majority are quiet, having, indeed, a 
degree of mental dulness, but being able to appreciate questions when 
aroused and answering correctly. Subsultus tendinum and carphologia, 
which som.e exhibit, show that there is profound disturbance of the nervous 
system. Epistaxis occurs occasionally in the first week, as in the adult, but is 
usually slight. 

The rose-colored eruption appears in children as well as adults between 
the sixth and twelfth days, but is more frequently absent in the former than 
the latter ; sometimes the number of spots is less than half a dozen. Sudamina 
are common in the second and third weeks, and perspirations may occur at any 
time in the course of the fever, but without amelioration of symptoms. More 
or less deafness is common, being in most instances a purely nervous symp- 
tom, without, therefore, any structural change in the ear, but it is possible, 
as has been suggested by certain writers, that it sometimes results from 
inflammatory thickening of the Eustachian tube or external meatus, or from 
a weakened and flabby state of the muscles of the ear. 

Duration. — As in diphtheria, so in typhoid fever, the duration varies 
greatly in difl"erent cases. Mild forms of the disease terminate within one 
week, but cases of a severe type may continue several weeks. Henoch states 
that the duration of 80 cases which he observed were as follows : from seven 
to ten days, 11 ; from ten to fifteen days, 26; from fifteen to twenty days, 
16; from twenty to thirty days, 21 ; and from thirty to forty-nine "days, 6 
cases. The limits in the duration were therefore seven days in the shortest 
and mildest cases, and forty-nine days in those that were the most protracted. 
In the cases of short duration the diagnosis was rendered clear by the roseola, 
enlargement of the spleen, and diarrhoea. When the disease begins to abate, 
there is frequently in the morning a complete apyrexia and a return of the 



COMPLICATIONS. 463 

fever in the latter part of the day. This period of an intermittent fever 
usually varies from two to five days. Forchheimer, who observed a severe 
epidemic of typhoid fever in Cincinnati, says that this disease in children 
sometimes terminates in six days (^Columbus 3Ied. Jour., 1888). In a discus- 
sion relating to typhoid fever at a recent session of the New York Medical 
Association, Dr. E. G. Janeway also stated that this disease sometimes termi- 
nates within ten days. In cases continuing three or four weeks the patient 
becomes progressively more emaciated and feeble, and in a severe form of 
the disease his condition seems very unpromising to one not familiar with the 
clinical history of the fever. Pale, emaciated, and feeble, probably passing 
his evacuations in bed, and taking little notice of objects around him, he 
presents at the close of the third week or in the fourth an appearance of 
helplessness, notwithstanding the best nursing and the constant employment 
of sustaining measures, which is truly discouraging. 

Relap>ies — Second Attacks. — Rilliet and Barthez called attention to the 
fact that relapses sometimes occur, although they observed only 3 such 
cases in 111 patients. Henoch witnessed 21 relapses in 137 cases, the relapses 
occurring after severe and after mild cases. The majority of the cases in 
which relapse occurred were, however, mild. As a rule, the relapse occurred 
between the third and fifth weeks, and after a complete apyrexia of three to 
ten days. In one case even eighteen days of apyrexia 'had occurred when 
the fever was renewed. In some cases the relapse took place during the 
decline of the fever, when there was a morning intermission and an evening 
fever, the fever again becoming continuous. Eichhorst, in examining the 
records of 666 cases occurring in Zurich, ascertained that second attacks 
occurred in 28 persons, or in 4.2 per cent, of the cases. He has observed 
cases of a third and even of a fourth attack, so that, as in diphtheria, a first 
or even a second attack does not destroy the susceptibility to the disease. 

Complications. — The chief complications of typhoid fever are broncho- 
pneumonia, already sufficiently described, enteritis, intestinal hemorrhage, 
peritonitis, otitis, parotiditis, and muguet. In one instance I lost a patient 
about ten years old, in whom the fever had nearly terminated, by the sudden 
accession of croup. There is, as we have seen, in ordinary cases more or less 
inflammation of the mucous membrane of the air-passages and of the intes- 
tines, especially in the vicinity of the patches of Peyer. It is easy to under- 
stand how, under circumstances which may arise in the fever favorable to 
the development of mucous inflammations, the bronchitis and enteritis may 
so increase as to constitute complications. They are the most frequent of 
the serious complications. 

Feeble action of the heart, common in severe cases of typhoid fever, and 
which after the second week is partly attributable to granulo-fatty degenera- 
tion of the muscular fibres of the heart, which is frequent in grave forms of 
the infectious diseases, obviously favors the occurrence of bronchial and pul- 
monary congestion. Hence the proneness in these cases of the inflammation 
to extend downward from the larger to the smaller bronchial tubes and to 
the lungs, so that broncho-pneumonia becomes an occasional very grave com- 
plication. 

In the child as well as adult with this disease the mucous membrane of 
the lower part of the ileum in the vicinity of Peyer's patches is frequently 
thickened and hyperaemic — a true intestinal catarrh. We can readily under- 
stand how under certain circumstances this may become aggravated so as to 
constitute an intestinal inflammation of considerable extent and gravity, a 
severe entero-colitis, so that the local symptoms predominate over the consti- 
tutional and aggravate the latter. 

In the adult, as is well known, the Peyerian and solitary glands, becom- 



464 TYPHOID FEVER. 

ing more and more prominent by proliferation of the cellular elements 
(the lymphoid cells), begin to ulcerate in the second week, and slough in the 
third, forming the typhoid ulcer, which is slow in healing and aids in 
keeping up the diarrhoeal state. Such destructive or necrotic inflammation 
is rare in young children, but it may occur in those of a more advanced 
age. 

Intestinal hemorrhage is therefore an occasional accident. Hillier met 
4 cases in 30 of the fever. It indicates the presence of ulcers upon the sur- 
face of the intestines. The younger the child the less the liability to it. 
Some in whom it has occurred recover, but others die. A girl of nine years 
complained of severe abdominal pain on the seventeenth day of the fever, 
which was followed by syncope and death. At the autopsy one of Peyer's 
patches was found deeply ulcerated, and at the bottom of the ulcer was a 
perforation through which blood had escaped into the peritoneal cavity. 

Intestinal perforation is more rare in children than in adults, as might be 
inferred from the statement already made that intestinal ulceration is less 
frequent and extensive in them. Statistics show that perforation in children 
occurs only once in 232 cases. Therefore, as perforation is the common cause 
of peritonitis in this disease, this inflammation is a rare complication. Peri- 
tonitis may, however, occur in typhoid fever without perforation. In one 
such case (an adult) in the fever wards attached to Charity Hospital local 
peritonitis with fibrinous exudation occurred opposite two ulcerated patches 
of Peyer, the ulcers extending nearly to the peritoneum, but not perforating. 
The lesions observed in this case throw light on those cases of peritonitis 
complicating typhoid fever which recover, the cause of which has received a 
different explanation. 

In advanced and greatly debilitated cases thrush sometimes appears in the 
interior of the mouth and upon the fauces. It is always an unfavorable 
prognostic symptom in children suffering from chronic or protracted disease. 
Parotiditis is also a rare complication. Otitis, commencing with pain and 
producing a discharge which may continue for weeks, is not rare, though 
less frequent than in scarlet fever. The otitis is commonly external, but it 
may in scrofulous subjects extend to the middle ear. 

Diagnosis. — This is more difiicult in children than in adults, and the 
younger the child the greater the difficulty. In infants protracted entero- 
colicis, with fever and a dry furred tongue, cannot in certain cases be 
positively diagnosticated from typhoid fever by the symptoms and clinical 
history. Typhoid fever is believed, however, to be rare at this age, for an 
infant nourished at the breast is very seldom exposed to the cause of the 
disease. When, however, as now and then happens, a young child presents 
the symptoms characteristic of protracted subacute entero-colitis or typhoid 
fever, and older members of the household have the fever, it is highly 
probable that the case is one of the latter disease, and it should be treated 
accordingly. 

Even in older children typhoid fever is frequently mistaken for simple 
subacute enteritis or entero-colitis, or vice versa. The following facts aid in 
the differential diagnosis : In typhoid fever there is a total loss of appetite, 
while in the subacute intestinal inflammation food is not entirely refused. 
Diarrhoea commences early in the inflammation, while in the fever it is not 
ordinarily till after the lapse of a few days. Abdominal tenderness in the 
fever is not appreciable or is located in the right iliac region ; in the other 
disease it is general over the abdomen or located in the umbilical region. 
In typhoid fever there is bronchitis with a cough, which is absent in the 
inflammation. In typhoid fever there are certain other symptoms, more 
or fewer of which are present in most cases, and which do not occur in the 



TREATMENT. 465 

intestinal diseases, except as a coincidence ; for example, headache, epistaxis, 
stupor, delirium, and perhaps the rose-colored spots. The evening rise of 
temperature and enlargement of the spleen are also important diagnostic 
symptoms. When it is very important to make a positive diagnosis, cultures 
may be made from blood drawn from the spleen, from the sediment of albu- 
minous urine, or from the feces, and if the disease be typhoid fever the 
specific bacillus will be found. 

Typhoid fever may be mistaken for meningitis during the first week, but 
in meningitis there is more constipation, irritability of stomach, and less ele- 
vation of temperature. Moreover, in meningitis at a comparatively early 
stage we are able to detect patches of congestion of the features coming and 
disappearing suddenly, and slight inequality of the pupils or their oscilla- 
tion when the light is uniform — signs which are lacking in typhoid fever. 
In a doubtful case the ophthalmoscope might be employed, which in menin- 
gitis discloses congestion of the vessels of the retina, oedema, etc. — anatomi- 
cal changes which do not pertain to typhoid fever. 

The difi'erential diagnosis of typhoid fever and acute tuberculosis may be 
made by attention to the following points : In tuberculosis there is cough, 
with some acceleration of respiration from the first, without epistaxis, stupor, 
or other nervous symptoms, and without the abdominal symptoms which are 
so prominent in the fever. The occurrence of typical cases in the same 
house or in those who have been similarly exposed has in certain instances 
enabled me to make a clear diagnosis. 

In localities where diseases due to marsh miasm occur, the remittent fever 
arising from this cause and typhoid fever bear considerable resemblance to 
each other. The two, indeed, may coexist — a fact observed during the late 
Civil War, so that cases in which this coexistence occurred were designated 
typho-malarial. In malarial remittent fever the commencement is more 
abrupt, the vomiting and headache more severe, and the remissions more 
marked than in typhoid fever. Moreover, quinine exerts a decided control- 
ling eifect in the fever due to marsh miasm, while its effect in typhoid fever 
is much less pronounced. 

Prognosis. — A much larger percentage of children recover than of adults. 
Although there be great emaciation with loss of strength, recovery may be 
confidently predicted, provided that no serious complication occur. Grrave 
symptoms, as high fever, delirium, severe diarrhoea, an unusually rapid and 
feeble pulse, have a bad import. If from any cause the system is in a 
marked degree debilitated when the fever begins, the prognosis is much less 
favorable than in those who are robust. Thus the presence of hereditary 
syphilis, of tuberculosis, of severe scrofula, or of bronchial or intestinal 
catarrh when typhoid fever begins, greatly increases the danger. But in 
fatal cases which I have met the unfavorable result occurred, as a rule, from 
the complications rather than directly from the malady. Of the compli- 
cations, the most serious are intestinal ulceration, giving rise to hemor- 
rhage, or even perforation, and consequent peritonitis, diphtheria, pneu- 
monia, nephritis, pleuritis with serous or purulent effusion, meningitis, and 
granulo-fatty degeneration of the myocardium. Complications like these 
largely increase the mortality of typhoid fever. The condition in which 
severe typhoid fever leaves a patient is favorable for the development of 
tubercles, and now and then they occur, disappointing our expectations and 
prediction of recovery. The possibility of a relapse should be borne in 
mind, so that the patient should remain in bed, free from excitement and 
with plain but nutritious and easily digested diet, until convalescence is well 
advanced. 

Treatment. — Typhoid fever, like typhus, cannot be abridged by treat- 
30 



466 TYPHOID FEVER. 

ment, and the indication is to sustain the vital powers, diminish the intensity 
of the fever, and arrest if possible any untoward symptom or complication. 
Quinia, so useful in malarial diseases, may be administered in small doses 
for its tonic effect and as an aid in promoting digestion. It is commonly and 
properly prescribed in some convenient vehicle for this purpose, but it does 
not antagonize the typhoid as it does the malarial poison. Perturbating 
medicines, and especially cathartics, should be given with caution. The 
tendency to intestinal ulceration and hemorrhage and the anaemic nature 
of the fever require abstinence from or cautious use of such agents. A 
temperature remaining under 103° usually involves little danger. If it 
remain above 103° morning and evening, antipyretic measures should be 
employed. I therefore order the nurse to bathe frequently the forehead, 
face, hands, arms, neck, and sometimes the chest, with cold water, to which 
it is proper to add alcohol or some spirituous lotion. A cloth wrung out of 
ice-water or an ice-bag should be applied over the head, and the hands may 
be allowed to lie a considerable time in a washbowl containing the lotion, 
which is always grateful to the patient. The water treatment thus applied 
will usually reduce the temperature one, two, or three degrees within a few 
hours. Cold general baths are not so well tolerated by children as by adults. 
Collapse has sometimes followed their use. and, on the other hand, benefit 
has apparently in some cases accrued from their employment when the tem- 
perature was above 104°. The bath, if used, should be at a temperature of 
about 88°, and the patient should not be immersed in it longer than five to 
eight minutes (Henoch). It seems preferable, however, in most cases of high 
temperature, to endeavor to reduce it by cold sponging or cold compresses. 
A compress frequently wrung out of ice-water or containing broken ice mixed 
with bran, or a rubber ice-bag applied over the head and another over the 
abdomen, or Leiter's coils applied over the same parts as the compress, arad- 
ually abstract the heat, and with more safety to the patient than the use of 
the cold bath. Ice applications should be discontinued if the temperature 
fall to 103° or if the patient complain of chilliness. Even an afternoon tem- 
perature of 104° does not require ice applications or any active antipyretic, 
provided there is a decided morning remission. Moderate doses of quinine 
and general sustaining remedies suf&ce for such cases. 

Of the internal antipyretics, sodium salicylate, antipyrine, phenacetin, 
acetanilide, and quinine have been chiefly employed. The sodium salicylate 
is likely to retard digestion, and it sometimes causes albuminuria. Its use, 
therefore, cannot be recommended, Antipyrine effectually reduces the tempera- 
ture, but is depressing. It may be given, especially in the early stages of typhoid 
fever, in doses of two to five grains according to the age, along with an alco- 
holic stimulant, with a good result. Some physicians recommend the use of 
phenacetin instead of antipyrine, as being equally effectual and less depress- 
ing. It may be given in about half the dose of antipyrine. Acetanilide in 
one-fourth the dose of antipyrine also reduces the fever, but it is also depress- 
ing, and it does not, so far as I am aware, possess any advantages over anti- 
pyrine. In the majority of cases the reduction of temperature is best effected 
by cold-water bathing, or cold compresses and the internal use of quinine. 
Quinine in moderate doses as a tonic appears to be useful during the entire 
course of the fever, but in cases of a temperature dangerously high antipy- 
rine, acetanilide, or phenacetin is now preferred by good observers to the use 
of large doses of quinine, which were formerly employed (Von Ziemssen). 

The fact that iri a large proportion of cases the typhoid bacillus enters 
the system in the ingesta, and effects a lodgment upon the gastro-intestinal 
surface, suggests the query whether the early use of antiseptics administered 
by the mouth might not be destructive to the bacillus, and thus in a measure 



TREATMENT. 467 

destroy the cause of the disease. The remedy which has thus far been used 
for this purpose, and which is supposed by some to exert a specific action 
upon the disease, apart from its purgative or eliminative effect, is calomel. 
Its mode of action is not fully understood. It is supposed by some to be in 
part changed into the bichloride in the stomach and intestines. Yon Ziems- 
sen in treating adults administers earl}^ in the attack three 7J-grain doses of 
calomel at intervals of two hours, and obtains by so doing a considerable 
reduction of temperature during the following twelve hours. Liebermeister 
claims that the use of calomel diminishes the intensity of the disease, and 
Wunderlich even believed at one time that it might abort the fever. On the 
other hand, Weil, Griesinger, and Baumler assert, from their observations 
and statistics, that the mortality is not diminished nor is the number of aborted 
cases increased by the use of calomel, and that it is only useful as a mild, 
non-irritating evacuant. Wilson says : '■ Attempts to fix the hypothetical 
specific action by long-continued calomel treatment, and to force a true abor- 
tive calomel treatment, have at difi'erent times failed, as has also the subli- 
mate treatment of typhoid fever." The use of calomel should probably be 
restricted to one or a few doses at the commencement of the attack. 

Since it is impossible to arrest typhoid fever or abridge its duration by 
any therapeutic measures of which we are cognizant, the indication is to sus- 
tain the vital powers and alleviate, so far as possible, the symptoms. Qui- 
nine is not only employed in large doses to reduce the fever, but it is often 
prescribed in small doses during the subsequent progress of the disease, in the 
belief that it may exert some tonic efi'ect. It does not appear, however, to 
exert any marked controlling eifect upon the symptoms. Iodine, iodide of 
potassium, and carbolic acid have also been employed internally, but their 
efficacy is doubtful, but Liebermeister states that the iodide of potassium 
employed in two hundred cases, although it did not appreciably ameliorate 
the symptoms, apparently diminished the mortality. 

The mineral acids have also their advocates, and statistics appear to show 
benefit from their use. The late Prof. Austin Flint treated 78 patients with 
the acids with a death-rate of 10.25 per cent, and 70 patients without the 
acids with a death-rate of 20 per cent., the treatment otherwise of the two 
classes being alike. The mineral acid which, in my opinion, is most useful is 
the muriatic, since it aids digestion, which is greatly impaired by the fever, 
and since the digestive ferments in this disease are apparently secreted in 
insufficient quantity. I usually prescribe this acid with pepsin, as in the 
following formula : 

R. Pepsini puri, in lamellis, ^j ; 

Acidi muriat. dilut., ^ij ; 

Syr. simplic, ,^ ; 

Aquae, ^iij. Misce. 

Give one teaspoonful in water every two hours to a child of ten years. The 
wine of pepsin of tlie National formulary may also be employed, but each 
teaspoonful contains only about one minim of the dilute muriatic acid, so 
that the quantity of the acid might be increased. 

In all but the mildest cases alcoholic stimulants are required, especially 
after the first week. In the first week they may be withheld in ordinary 
cases, but in attacks of a severe type and attended by early prostration they 
may be required at or soon after the commencement of the fever. The indi- 
cations for their use are feeble pulse with faint systolic sound and marked 
nervous symptoms, as subsultus tendinum, stupor, and delirium. In the 
prostration consequent on high fever and protracted and obstinate diarrhoea 



468 TYPHOID FEVER. 

the use of alcoliol is important as a cardiac stimulant. Still, such large and 
frequent doses of the alcoholic compounds are not needed as are useful in 
diphtheria. The object in employing them is to sustain the flagging pulse 
and promote digestion and assimilation. The preferable mode of employing 
alcoholic stimulants is in the form of milk punch or wine whey. 

Wakefulness, which is sometimes an unpleasant symptom, and which may 
occur with, and is perhaps largely due to, the headache, may be relieved by 
a powder of phenacetin and bromide of potassium or sodium, two to five 
grains of the former and double or treble its amount of the bromide. The 
new remedy, sulphonal, triturated and given in sweetened water or milk, 
will also relieve the insomnia, and in some instances it appears to be pref- 
erable to the other agents which have been employed for the purpose of 
procuring sleep. An opiate, as Dover's powder, is also useful in relieving 
wakefulness, and should be prescribed if the patient at the same time have 
diarrhoea. Three grains may be given to a child of eight years. For head- 
ache, whether accompanied by wakefulness or not, I know no better remedy 
than phenacetin in combination with the bromide of potassium or sodium, as 
given above. At the same time, cool lotions should be applied to the head. 
The same remedies which are appropriate for the insomnia are also useful for 
the delirium which occasionally occurs in cases of a grave type. The con- 
stant application of cold to the head and an increase in the stimulation may 
also be required. 

We have stated elsewhere that diarrhoea is less common in the typhoid 
fever of children than in that of adults, but it sometimes occurs, and should 
be promptly checked. The subnitrate of bismuth in rather large and fre- 
quent doses, along with an opiate and vegetable astringent, will usually con- 
trol the diarrhoea, and the same remedies should be employed in intestinal 
hemorrhage. Recently in my practice in the case of a boy of about fifteen 
years near the close of the second week of typhoid fever, so large a flow of 
blood occurred from the intestines that the condition of the patient was very 
critical. But the loss of blood was quickly checked by large doses of sub- 
nitrate of bismuth and teaspoonful doses of equal parts of the camphorated 
tincture of opium and tincture of catechu, and the patient recovered. The 
constipation which is sometimes present in typhoid fever, and more frequently 
in children than in adults, may be relieved by an enema of water, half a pint 
containing one or two teaspoonfuls of glycerin. 

The distension of the stomach and intestines with flatus is sometimes so 
great that it requires treatment. It may cause a sensation of fulness and 
prevent the descent of the diaphragm in respiration, and it increases the dan- 
ger of perforation if a deep intestinal ulcer exist. External pressure and 
manipulation should not be employed under such circumstances, since they 
might cause rupture, nor should the hypodermic needle be used. Jacobi has 
witnessed a fatal peritonitis produced by the escape of fecal matter through 
the punctures caused by the needle (Arch, of Pediatrics, Dec, 1888). The 
proper remedy for the fl-atus is either turpentine or the aniseed cordial of the 
National Formulary. 

Sustaining measures are of the highest importance. Typhoid fever ceases 
after some days or weeks with or without medicinal treatment, and the patient 
recovers if the strength be adequately supported. Hence the food should be 
sufficient in quantity, of the most nutritious kind, and easily digested and 
assimilated. It must be liquid, since the repugnance to food and the mental 
state of the patient render it impossible to feed him with solids unless in the 
mildest cases. Milk sterilized by heat or peptonized, the meat broths, and 
gruels with milk must be the food chiefly employed. Since the digestive 
ferments are apparently secreted in small quantity during the fever and diges- 



TREATMENT. 469 

tion is feebly performed, it is well to employ predigested food when the disr 
ease is unusually severe and the temperature very high. Peptonized milk 
and the beef peptones of the shops are useful under such circumstances. 
Milk with some farinaceous food long boiled, as barley flour, should in most 
instances be employed as the principal article of diet. The mistake is some- 
times made by anxious friends of giving the nutriment too frequently, even 
every half hour. As in health, so in this disease, the digestive function 
requires intervals of rest, so that, as a rule, the food should not be given 
oftener than every two hours, and then in sufficient quantity. A dose of 
pepsin before each feeding, employed in the formula recommended above, 
has been useful in critical cases in my practice. So important is the diet in 
typhoid fever that the physician neglects an important duty if he do not give 
as full and explicit directions in regard to the feeding as he does in refer- 
ence to the use of medicines. The room occupied by the patient should be 
large and well ventilated. Statistics show that the result is far better if there 
be a plentiful supply of pure fresh air than in closed and ill-ventilated apart- 
ments ; so that in some of the hospitals patients are treated in canvas tents 
upon the hospital grounds when the weather is suitable. Nearly forty j^ears 
ago an emigrant-ship arrived at Perth Amboy, N. J., with more than 300 
passengers, 82 of whom were sick with fever, and several had died at sea. 
There being no hospital in the town, the fever patients, 12 of whom were 
insensible, were placed in hastily-constructed wooden shanties with sail roofs. 
To add to their discomfort, a violent thunder-storm occurred which drenched 
the interior of the shanties, and yet with simple medicinal treatment and the 
use of buttermilk and animal broths only 1 of the 82 patients died. Four 
sailors who sickened with the fever after the arrival of the vessel were taken 
to a dwelling-house, and two of them died. These facts, which were related 
to the New York Academy of Medicine at the June meeting in 1853 by the 
late Dr. John H. Griscom, and were published in the Transactions of the 
Academy for that year, strongly impressed the profession of New York with 
the importance of fresh air in the treatment of typhus and typhoid fevers, 
and the knowledge thus obtained has no doubt been instrumental in saving- 
many lives. But in the treatment of children the sudden reduction of tem- 
perature and currents of cold air should be avoided, for by taking cold the 
bronchial catarrh which is ordinarily present in a mild form might be aggra- 
vated, or a croup or pneumonia might be developed. 

Von Ziemssen states that in severe cases attended by feeble heart-action 
the patient should not be allowed to move without assistance or get out of 
bed, for sudden heart-failure and death " frequently result from a neglect of 
this rule " (^Annual of Med. Sci.^ vol. i., 1888). The occurrence of bed-sores 
should be guarded against by change of position and the use of a soft mat- 
tress or water-bag. In severe cases attended by much prostration the patient 
should not be allowed to leave the bed until some days after the fever has 
ceased and the strength is in a measure restored. 

Prophylaxis. — The duty of the physician does not cease with the care of 
the patient. He should employ efficient measures to prevent the propagation 
of the disease. Especial attention should be given to the disinfection of the 
excreta. This may be accomplished by adding six ounces of chloride of 
lime to one gallon of water, and mixing one quart of this solution with each 
fecal evacuation and a less quantity with each urinary discharge. Crude 
carbolic acid (one part to ten or fifteen of water), sulphate of copper (one 
part to twenty of water), or, best of all, corrosive sublimate (one part to two 
hundred to four hundred of water) may be employed for the same purpose. 
The disinfected discharge should be allowed to stand a few moments before 
it is emptied into the water-closet, and the closet should be thoroughly flushed 



470 CEREBROSPINAL FEVER. 

out. In country practice great care must be taken that the discharges be not 
emptied in such a place that they can by any possibility percolate into the 
well which supplies the drinking water to the families or neighbors. A pound 
or more of corrosive sublimate in solution should be sprinkled in the vault, 
and chloride of lime should be dusted over the contents. The milk used in 
the family should be sterilized by steaming two hours at a temperature of 180° 
to 190°, or by boiling, and the drinking water should be boiled or distilled. 
Care should be taken to disinfect promptly the clothing worn by the patient 
and the bedding. This may be accomplished by placing them immediately 
when removed in boiling water or by immersing them in a solution of corro- 
sive sublimate (one part to one thousand), or carbolic acid (one part to fifty), 
or sulphate of copper or chloride of lime (one part to one hundred). 



CHAPTER IV. 

CEREBEO-SPINAL FEVEK. 

Definition. — Probably a microbic disease. It is manifested chiefly by 
the occurrence of cerebro-spinal meningitis. Its prominent symptoms are 
such as meningitis gives rise to — to wit, fever, headache, tonic contraction 
of the muscles of the nucha, hyperaesthesia, and neuralgic pains in the trunk 
and extremities. It is non-contagious or contagious in a very low degree, 
and, as with most of the microbic diseases, its victims are chiefly the young. 
It is ordinarily a pa-imary disease, but it sometimes occurs as a complication 
of other acute as well as chronic maladies. It begins abruptly or without a 
premonitory stage, and it is often speedily fatal from the intense hyperaemia 
of the nervous centres or the severity of the cerebro-spinal meningitis. In 
other cases, after weeks or months of sufiering and progressive loss of flesh 
and strength, death occurs in a state of extreme prostration. In those who 
recover convalescence is protracted and slow. 

This disease has been designated by different terms in diff'erent countries, 
as spotted fever, cerebro-spinal fever, malignant purpuric fever, typhus petech- 
ialis, typhus syncopalis, and febris nigra, expressive of its constitutional 
nature. Those who employ such terms regard it as a general or systemic 
disease, with the meningitis as its local manifestation, just as pharyngitis 
is a local manifestation of scarlet fever or bronchitis of measles or pertussis. 
This opinion of its nature receives strong support from the clinical fact that 
in severe forms of the disease extravasations of blood occur early under the 
skin, indicating a profoundly altered state of the blood and systemic infec- 
tion. The disease has also been designated by terms expressive of its local 
nature, as epidemic meningitis, epidemic cerebro-spinal meningitis, typhoid 
meningitis, malignant meningitis. We will treat hereafter of the nature of 
this malady, and endeavor to justify the opinion which has led to the use of 
terms that indicate its constitutional character. 

History. — Whether cerebro-spinal fever occurred previously to the pres- 
ent century is uncertain. If it did it was confounded with other diseases. 
Vieussens in 1805 was apparently the first who wrote a clear and unmistak- 
able description of it, designating it " a malignant non-contagious fever." He 
described an epidemic of it which appeared in Geneva, Switzerland, in a 
family of 3 children, of whom 2 died in twenty-four hours. Two weeks 
later 4 children in another family died of it, after an illness of less than a 



HISTORY. 471 

day, and a young man in another house died with similar symptoms after an 
equally brief illness, his surface having a deeply congested or violet appear- 
ance. In these and subsequent cases the attack began in the latter part of 
the day or at night, and was attended by vomiting, violent headache, convul- 
sions, dysphagia, petechias, and tonic contraction of the posterior muscles of 
the neck and trunk, producing retraction of the head and opisthotonos. 
Thirty-three lost their lives during this epidemic, after a sickness varying 
from twelve hours to five days. Within the next two years epidemics of 
cerebro-spinal fever occurred in Bavaria, Holland, Germany, and at about 
the same time or soon after in parts of England. 

The first American cases of the disease, so far as is now known, were at 
Medfield, Massachusetts, in 1806. From 1806 to 1816 occasional outbreaks 
of it occurred in England, France, and America in several localities. It 
appeared in both Canada and the United States. From 1816 to 1828, so far 
as is now known, only two epidemics of it occurred, and they were limited to 
small areas and were of brief duration. The one was at Middletown, Con- 
necticut, and the other at Vesoul, France. In 1828 it occurred in Trumbull 
county, Ohio, in 1830 at Sunderland, England, and in 1833 at Naples. After 
the Naples epidemic a respite from the disease appears to have occurred, in 
both the Eastern and Western Hemispheres, until 1837. In that year it 
appeared in the South of France, in and around Bayonne, and gradually 
extended to isolated localities over almost the whole of France. It occurred at 
this time among troops in their barracks as well as civilians, and in some local- 
ities of the troops afi'ected from 50 to 75 per cent. died. Even Versailles and 
Paris did not escape. During the twelve years from 1837 to 1849, France 
suiFered far more than any other country from this disease. It was espe- 
cially common and fatal among the soldiers in many localities, and at some 
of the military stations in France several successive epidemics occurred. In 
the decade from 1839 to 1849 cerebro-spinal fever extended to Naples, the 
Romagna, Sicily, Gibraltar, Algeria, and various places in Denmark, England, 
and Ireland. 

In 18-12 the United States was again visited by cerebro-spinal fever in 
localities at a distance from the seaboard, and therefore, apparently, not by 
communication from Europe. In 1842-43 it occurred in Kentucky, Tennessee, 
Alabama. Illinois, Mississippi, and Arkansas. From 1840 to 1850 it visited 
Montgomery in Alabama, Beaver county in Pennsylvania, Cayuga county in 
New York, and New Orleans in Louisiana. Between 1850 and 1854 there 
is no record of its occurrence in either hemisphere, but from 1854 to 1860 
it ravaged the Scandinavian peninsula and caused more than four thousand 
deaths. 

Since 1860 certain localities in nearly every civilized country have been 
severely visited by this disease. In all these countries it is justly regarded 
as one of the most fatal and important of the epidemic maladies. 

An interesting fact in regard to these many epidemics on both continents, 
which have been reported by competent observers, is that they have occurred 
in isolated localities far apart and without the least evidence of transportation. 
Cerebro-spinal fever has not, so far as I am aware, in any instance extended 
from one locality to an adjacent one in the manner of contagious diseases. 
The cause of the malady has evidently arisen or been created in the places 
where the cases have occurred, and is not susceptible of transportation so as 
to produce the disease elsewhere. Cerebro-spinal fever resembles in this 
respect the diseases due to marsh miasm. 

But since 1860 this disease has appeared in this country in another phase. 
It has become or is being established — or, to use the phrase commonly 
employed in medical literature, naturalized — in the cities of the United States. 



472 CEREBROSPINAL FEVER. 

For some years not a week has passed without the report of deaths from this 
cause in New York, Philadelphia, Jersey City, and Chicago. It is probably 
already permanently established in Cincinnati, St. Louis, Minneapolis, New- 
ark, and San Francisco, since deaths from it have been reported it these cities 
during many consecutive weeks. 

In New York City prior to 1866 only 4 deaths occurred from what was 
perhaps cerebro-spinal fever, since in 1838 2 deaths were reported from 
so-called spotted fever, 1 in 1850 and 1 in 1861. What was the nature of 
this spotted fever is now a matter of conjecture. In 1866, 18 patients died 
of cerebro-spinal fever within the city limits, and not a year has passed since, 
and in the last few years not a week, without deaths from it. From 1866 to 
1872 the annual deaths from this disease in New York varied from 18 to 48. 
Commencing in December, 1871, and continuing during the first half of 
1872, a severe epidemic occurred, producing a large mortality. Many who 
recovered permanently lost their hearing and some their sight from the attack. 
In this epidemic the physicians of New York were fully aroused to the 
importance of the disease which was causing so much suffering, and which 
attacked the lower animals, especially the jaded horses of the city car- and 
stage-lines, not a few of them dropping down in harness, so suddenly did the 
attacks occur. In 1872, 782 deaths, chiefly of children, resulted from 
cerebro-spinal fever within the city limits. This epidemic appeared to pro- 
duce a greater dissemination of the disease and more firmly established it in 
the city, for since then the annual deaths from it have varied between 97 in 
1878 and 461 in 1881. In Philadelphia cerebro-spinal fever began in 1863, 
causing 49 deaths in that year, and it has never been absent from that city 
since. Prof. Stille states that between 1863 and 1882 it has caused 2049 
deaths within the city limits. In Philadelphia, as in New York, it has for 
some years produced a nearly uniform weekly mortality. The prevalence of 
cerebro-spinal fever in the United States and its probable importance in the 
future may be inferred from the fact that it has recently occurred also in 
Cincinnati, Minneapolis, Denver, Norfolk, Boston, AYorcester, New Haven, 
Albany, Syracuse, Auburn, Milwaukee, Wilmington, Detroit, Baltimore, 
Charleston, Toledo, Mobile, Salt Lake, Grand Bapids, Providence, Chatta- 
nooga, Hartford, New Orleans, Fall Biver, Bichmond, Knoxville, and 
Nashville. 

Etiology. — That this disease is produced by a micro-organism is gener- 
ally believed. Dr. A. Frankel and other European microscopists have care- 
fully examined the bacteria found in the blood and tissues of those affected 
by it. At a meeting of the Berlin Medical Society, held February 12, 1883, 
Herr Leyden showed under the microscope specimens of micrococci found 
in a case of cerebro-spinal fever. They had an oval shape, were mostly in 
pairs, and were faintly tremulous. They resembled those found in pneu- 
monia and erysipelas, but Leyden did not think them identical. At the 
same meeting Herr Baginsky related cases which seemed to show that in 
some instances the cause of cerebro-spinal fever and that of pneumonia might 
be identical.^ 

Dr. V. 0. Pushkareff, connected with one of the barrack-infirmaries of 
St. Petersburg, states that in five cases of croupous pneumonia in which 
cerebro-spinal meningitis occurred as a complication he discovered in the pus 
taken from the cerebral meninges swarms of micrococci whose appearance 
under the microscope seemed identical with that of Friedlander's pneumococ- 
cus. They were either isolated or in groups of two, seldom in four, having 
distinct capsules, and they were absent from the fluid taken from the men- 
inges in simple pneumonia. Pushkareff was .able to cultivate the micrococ- 
1 Deutsch. med. Wuchenschr., April 4, 1883. 



ETIOLOGY. 473 

cus taken from the meningeal pus, and the cultivated microbes, like their 
parents, presented an appearance identical with that of the pneumococcus.^ 
Moreover, Eberth, in a case of meningitis following pneumonia, believes that 
he found the same micrococcus in the lungs and in the liquid exuded from 
the inflamed pia mater. Frankel also states that he obtained from the puru- 
lent exudation in the pia mater, in a case of meningitis occurring with pneu- 
monia, a microbe resembling that in the pneumonic exudation. ' 

From the investigations of so many competent microscopists, therefore, 
it appears that the microbe found in the exudate of the meninges in cerebro- 
spinal fever, and which is supposed to sustain a causal relation to this disease, 
bears a close resemblance in form to the pneumococcus, if it be not identical 
with it. But we would infer, from the fact that croupous pneumonia is so 
universal a disease occurring in localities where there is no cerebro-spinal 
fever, that the cause of the two must be different, or, if there be a form of 
croupous pneumonia which is produced by the same microbe as that of 
cerebro-spinal fever, the pneumonia which is universal must have a different 
origin. The microbic causation of cerebro-spinal fever needs further inves- 
tigation, which it will doubtless receive, before positive statements can be 
made. 

Among the conditions which are favorable for the occurrence of cerebro- 
spinal fever, and may therefore be regarded as predisposing to it, we may 
mention the winter season. Statistics collected in Europe and the United 
States show that while 166 epidemics occurred in the six months commencing 
with December, only 50 were in the remaining six months of the year. Ac- 
cording to the statistics of Prof. Hirsch, which were collected mainly from 
Central Europe, 57 epidemics were in winter or in winter and spring, 11 in 
spring, 5 between spring and autumn, 4 commenced in autumn and extended 
into winter or into winter and the ensuing spring, and 6 lasted the entire 
year. I suspect that the opinion expressed by Prof Hirsch is correct, that 
the excess of epidemics in the winter months is due mainly to the greater 
crowding and less ventilation in the domiciles during the cold than during 
the warm months, especially among European peasantry. In New York 
City, where the state of the domiciles is about the same the year round, 
the season appears to exert little influence on the prevalence of the 
disease. 

The fact has repeatedly been observed that antihygienic conditions increase 
the liability to cerebro-spinal fever. Soldiers in barracks and the poor in tene- 
ment-houses sufi'er most severely when the epidemic is prevailing. In New 
York City the fact is often remarked that multiple cases occur for the most 
part where obvious insanitary conditions exist, as in apartments which are 
unusually crowded and filthy or in tenement-houses around which refuse mat- 
ter has collected or which have defective drainage. The interesting chart 
prepared under the direction of Dr. Moreau 3Iorris for the Health Board 
shows that comparatively few cases occurred in the epidemic of 1872 in those 
portions of the city where the sanitary conditions were good. Antihygienic 
conditions probably predispose to cerebro-spinal fever in the same way that 
they do to other grave epidemic disease, as, for example, to Asiatic cholera, 
whose ravages are chiefly where hygienic requirements are most neglected. 
We will presently relate striking examples which show how foul air increases 
the number and malignancy of cases. Insanitary conditions not only ener- 
vate the system and render it more liable to contract any prevailing dis- 
ease, but probably promote the development and activity of the specific 
principle. 

^ Fjen. kiln. Gazeta. April 21. 1885. 

^ Deutsch. med. Wochenschr., Nov. 13. 1886. 



474 CEREBROSPINAL FEVER. 



Is Cerebro- Spinal Fever Contagious? 

It is the almost unanimous opinion of those who are most competent to 
judge from their observations that it is either not contagious or is contagious 
in a very slight degree. It is certain that the vast majority of cases occur 
without the possibility of personal communication. Thus, in the commence- 
ment of an epidemic the first patients are affected here and there at a dis- 
tance from each other, often miles apart, and throughout an epidemic usually 
only one is seized in a family. Children may be around the bedside of the 
patient, passing in and out of the room without restriction, and yet we can 
confidently predict that none of them will contract the malady if there be 
proper ventilation and cleanliness and none of the conditions of insalubrity 
exist within or around the domicile. Moreover, when multiple cases occur 
in a family the disease begins at such irregular intervals in the difi"erent 
patients that there can be little doubt in most instances that it is not com- 
municated from one to the other, but, like the fevers from marsh miasm, is 
produced by exposure to the same morbific cause, existing outside the indi- 
viduals, but within or around the premises. Thus, in the Brown family 
treated by the late Dr. John G. SewelP of New York, the first child sick- 
ened January 30th, and subsequently the remaining five children at intervals 
respectively of five, seven, eleven, twenty-five, and forty-five days. That so 
many were aff'ected in one family was attributed by the doctor to the filthy 
state of the house and the bad plumbing, which allowed the free escape of 
sewer-gas. In my own practice, in the family which suffered the most 
severely of all, four patients were seized in succession, and yet I could see 
no evidence of contagiousness. The family occupied a small plot of ground, 
not more than thirty feet by one hundred, and their occupation was to pre- 
pare for the meat-market what is known as head-cheese. They lived on the 
second floor of the two-story wooden house in which the work was carried 
on. At the time of the sickness the shop contained four hundred heads of 
animals from which the meat for the cheese was obtained, and it was evident 
that decaying animal matter was present. The occupation and surroundings 
of this family afforded sufiicient explanation of the fact that so many were 
attacked. Two workmen contracted the disease within about one week of 
each other, and were removed from the house. On January 26th, four 
weeks after the commencement of the malady in the workman who was first 
attacked, one child sickened with it, and died on February 1st. Fifteen 
days subsequently (February 16th) a second child was attacked, and, after 
a tedious sickness, finally recovered. The long and irregular intervals 
between these cases indicate that the disease was not contracted by one 
from the other. The important factor in causing so severe an outbreak 
of cerebro-spinal fever in this family was probably the miasm produced by 
such an occupation in the house where the family resided, with neglect of 
ventilation and cleanliness. 

But the strongest evidence that cerebro-spinal fever is either noncon- 
tagious or very feebly contagious is afforded by the fact that a large majority 
of the cases occur singly in families, although there is no isolation of the 
patients. The following are the statistics relating to this point in the cases 
which I have observed since cerebro-spinal fever commenced in New York, 
in 1871: Single cases occurred in seventy families ; dual cases occurred in 
nine families ; three cases occurred in one family, and four cases in one 
family. Intercourse with the sick-room was unrestricted in all these fami- 
lies, so that children frequently went out and in, and sometimes assisted in 
the nursing. 

1 Medical Record, July, 1872. 



IS CEREBROSPINAL FEVER CONTAGIOUS? 475 

The most striking example of apparent contagiousness which has com^ 
to my knowledge was related by Hirsch, and is quoted by Von Ziemssen. 
A young man sickened with cerebro-spinal fever on February 8th. The 
woman who nursed him returned to her home in a neighboring village, and 
there died of the same disease on February 26th. To her funeral mourners 
came from a neighboring township, and after their return home three of them 
died with the same disease — one within twenty-four hours, another on ]\Iarch 
4th, and a third on the 7th. 

In one instance only in my practice did the facts point to contagiousness. 
A boy of twelve years died of cerebro-spinal fever, and was buried on Satur- 
day or Sunday. On Monday the mother washed the linen and bedclothes of 
the boy, which had accumulated and were in a very filthy state. Two days 
subsequently she was attacked, and her infant soon afterward, both perishing. 
The state of the bedding and apartments in this house, as seen by myself, 
was such as would be likely to concentrate and intensify the poison, render- 
ing it peculiarly active, for they were very dirty, and the mother, exhausted 
by her long and incessant watching and lack of sleep, and depressed by grief, 
rendered her system more liable to the disease by her self-imposed duties on 
the day after the funeral. One in her state of mind and body, standing for 
a considerable part of a day over the bedclothes and bedding of her child 
soiled by the excreta, would certainly be in a condition to contract the disease 
if it were contagious in any, even in the lowest, degree. In the present state 
of our knowledge, therefore, upon this important subject the evidence leads 
us to believe that with proper ventilation and cleanliness and the suppression 
of antihygienic conditions in an infected domicile those who are in a good 
state of body and mind will not contract the disease, but in the opposite con- 
ditions it is not improbable that the poison may be so intensified, and the sys- 
tem rendered so liable to receive the prevailing malady through impairment 
of the general health and diminished resisting power, that cerebro-spinal 
fever may, though rarely, be communicated either by the breath of the patient 
or by exhalations from his surface or from soiled clothing. 

The occurrence of cerebro-spinal fever in certain of the lower animals is 
a very interesting fact, especially as the question is sometimes asked whether 
it may not be communicated from them to man. In the epidemic of 1811 in 
Vermont, according to Dr. Gallop, even the foxes seemed to be aff'ected, so 
that they were killed in numbers near the dwellings of the inhabitants. 
Cerebro-spinal fever, previously unknown in New York City, began, as stated 
above, in 1871, among the horses in the large stables of the city car- and 
stage-lines, disabling many and proving very fatal, while among the people 
the epidemic did not properly commence till January, 1872, although a few 
isolated cases occurred in December of 1871. No evidence exists, so far as 
I am aware, that the disease was in any instance communicated by these 
animals to man. Those who had charge of the infected horses, as the veter- 
inary surgeons and stable-men, did not contract the malady, certainl}^ not 
more frequently than others who were not so exposed. Although we may 
admit slight contagiousness, there has probably been no well-established 
example of the transmission of cerebro-spinal fever from animals to man. 
If transmission ever does occur, it is so rare that practically no account need 
be made of it. 

In some instances we are able to discover an exciting cause. An indi- 
vidual whose system is affected by the epidemic influence may perhaps escape 
by a quiet and regular mode of life, but if there be any unusual excitement 
or if the normal functional activity of the system be seriously disturbed, an 
outbreak of the malady may occur. Among the exciting causes we may 
mention overwork and lack of sleep, fatigue, mental excitement, depressing 



476 CEREBROSPINAL FEVER. 

emotions, prolonged abstinence from food followed by over-eating, and the 
use of indigestible and improper food. Thus, in once instance among my 
cases a delicate young woman, at the head of one of the departments in a 
well-known Broadway store, was anxious and excited and her energies over- 
taxed at the annual reopening. Within a day or two subsequently the disease 
began. Another patient, a boy, was seized after a day of unusual excitement 
and exposure, having in the mean time bathed in the Hudson when the 
weather was quite cool. Those children have seemed to me especially liable 
to be attacked who were subjected to the severe discipline of the public 
schools, returning home fatigued and hungry, and eating heartily at a late 
hour. In one instance which I observed a school-girl ten years of age 
returned from school excited and crying because she had failed in her exami- 
tion and had not been promoted. In the evening, after she had closely studied 
her lessons, the fever began with violent headache. 

Dr. Frothingham^ writes as follows of the brigade in which cerebro-spinal 
fever occurred in the Army of the Potomac : " Under General Butterfield, a 
stern disciplinarian, .... the men were drilled to the full extent of their 
powers, often to exhaustion. I did not at the time recognize this as the 
cause of the disease in question, but I learnt that in the present epidemic in 
Pennsylvania the attack generally follows unusual exertion and exposure to 
cold." 

Many observers have noticed that bodily fatigue and mental depression 
and excitement are important factors in causing an attack of cerebro-spinal 
fever when this disease is epidemic. Dr. Gallop, in his history of cerebro- 
spinal fever as it occurred during the » war of 1812, directs attention to the 
severity of the cases among the troops under General Dearborn, who were 
fatigued by marches and greatly dispirited on account of a repulse which 
they had sustained from the British. In one case which occurred in my 
practice a boy, six years and eleven months of age, was punished at school 
and came home with cheeks flushed from excitement, the excitement con- 
tinuing during the ensuing night. On the following day cerebro-spinal fever 
began with vomiting and chilliness, the attack ending fatally on the seven- 
teenth day. In another case, which was related to me by the mother and 
the physician, the patient, a bright girl twelve years of age, of nervous tem- 
perament and forward in her studies, had been much excited in competing 
for a prize in athletic exercises. In the evening of the same day a violent 
thunder-storm occurred, and after a severe clap she started from bed pallid 
and excited, and expressed the belief that she had been struck by lightning. 
The disease began immediately after this, and terminated fatally on the fifth 
day. 

Secondary Oerebro-Spinal Fever. 

Fagge^ says : " Several observers have found that during or just after an 
epidemic of cerebro-spinal fever meningitis has presented itself with unusual 
frequency as a complication of other acute diseases." He mentions croupous 
pneumonia, pleurisy, acute tonsillitis, and scarlatinal nephritis as the diseases 
upon which it is very liable thus to supervene. In this respect cerebro-spinal 
fever resembles diphtheria and erysipelas, which we know are very liable to 
occur in those who are suffering from other diseases. 

A striking example of cerebro-spinal fever occurring as a complication 
was recently seen by me in consultation. A child of about ten years with 
typical typhoid fever had reached about the twelfth day of a mild form of 

' American Medical Timea, April 30, 1864. 
^ Practice of Medicine, vol. i. p. 614. 



SECONDARY CEREBROSPINAL FEVER. 



477 



the disease. The initial headache had ceased, there was no delirium, thfe 
temperature was but moderately elevated, and no doubt had arisen in the 
mind of the experienced physician in attendance that the disease, which 
presented the characteristic signs, would terminate favorably after the usual 
time. Suddenly violent headache occurred, the temperature rose to 103° or 
104° F., and in a few days fatal coma terminated the case. Another disease 
in which T have seen cerebro-spinal fever occur as a complication is gastro- 
intestinal catarrh. 

Sex. — It is stated by certain writers that more males are affected than 
females. The statistics of hospitals and camps show this, for men subject 
to lives of hardship are especially liable to be attacked ; but in family prac- 
tice, in which a large proportion of the patients are children, the number of 
males and females is about equal. Thus, in 105 cases occurring chiefly in 
my practice, but a few of them in the practice of two other physicians of 
this city, I find that 59 were males and 46 females : 91 of these were children. 
In Xew York City, during the epidemic of 1872, 905 cases of cerebro-spinal 
fever were reported to the Board of Health between January 1 and Novem- 
ber 1, and of these 484 were males and 421 females. Dr. Sanderson's 
statistics of the epidemic in the provinces around the Vistula, the cases 
being chiefly children, give also but a slight excess of males. Probably, there- 
fore, in the same conditions and occupations of life the sexes are equally 
liable to contract this malady, and the excess of males is due to the fact that 
they lead a more irregular life and are more subject to privations and 
exposures. That soldiers on duty in barracks have been attacked while 
families in the vicinity escape, thus increasing the proportion of male cases, 
must be due to irregularities, hardships, and perhaps the lack of sanitary 
regulations in their mode of life. 

Age. — My observations lead me to think that the younger the patient 
the more frequently is cerebro-spinal fever overlooked and some other disease 
diagnosticated. Nevertheless, all published statistics, so far as I am able to 
ascertain, show that a large proportion of cases occur under the age of five 
years, and that a larger proportion of fatal cases are in the first year of life 
than in any other year. Thus, in New York City the ages of those who died 
from this disease in 1883 were as follows : 



Under 1 year 57 

From 1 to 2 years 31 

From 2 to 3 " 22 

From 3 to 4 " . 12 

From 1 to 5 " 9 

From 5 to 10 " 37 

From 10 to 15 " 18 

From 15 to 20 " 15 



From 20 to 25 vears 7 

From 25 to 30 ' " 3 

From 30 to 35 " 4 

From 35 to 40 " 3 

From 40 to 45 *' 1 

From 45 to 50 " 2 

From 50 to 60 '' 1 

Over 60 years 1 



The following are the statistics of the New York Health Board relating to 
the ages of the cases during the epidemic of 1872 : 



Under 1 year 125 

From 1 to 5 years 336 

From 5 to 10 " 204 

From 10 to 15 " 106 



From 15 to 20 years 54 

From 20 to 30 " 79 

Over 30 years 71 

Total . 975 



In the cases which occurred in my own practice, and in a few cases in the 
practice of other physicians added to mine, I find that the ages were as 
follows : 



478 



CEREBROSPINAL FEVER. 



Under 1 year 16 

From 1 to 3 years 27 

From 3 to 5 " 25 

From 5 to 10 " 20 



From 10 to 15 years 10 

Over 15 years 15 

Total 113 



In my practice, therefore, three-fourths of the cases have been under the 
age of ten years ; and the statistics of epidemics in other localities correspond 
with mine in giving a large excess of cases in childhood. Thus, Dr. Sander- 
son, in examining the records of deaths in one epidemic, ascertained that 218 
had perished under the age of fourteen years, and only 17 above that age ; 
and although this does not show the exact ratio of children to adults in the 
entire number of cases, it is evident that the children were greatly in excess. 

The more advanced the age after the tenth year, the less the liability to 
this malady, so that very few who have passed the thirty-fifth year are 
attacked, and old age possesses nearly an immunity. In New York City, in 
which, as we have seen, cerebro-spinal fever has been occurring since 1871, 
only two cases have come to my knowledge which had passed the fortieth 
year. The age of one was forty-seven, and of the other sixty-three years. 
But nearly every year the statistics of the Health Board show that one or 
two old people have died of this disease. 

Not a few cases occur in this city in infants of the age of three or four 
months. An infant of four months died of cerebro-spinal fever in the New 
York Infant Asylum, the nature of the disease not being known until it was 
revealed by the autopsy. 

Symptoms. — During the prevalence of cerebro-spinal fever cases now and 
then occur in which the symptoms are mild and transient and the health is 
soon fully restored. It seems proper to regard some, at least, of these as 
genuine but aborted forms of the disease. The following cases which occur- 
red in my practice may be cited as examples : 

A boy eight years of age, previously well, was taken with headache and 
vomiting, attended by moderate fever, on April 2, 1872. The evacuations 
were regular, and no local cause of the attack could be discovered. On the 
following day the symptoms continued, except the vomiting, but he seemed 
somewhat better. On April 4th the fever was more pronounced, and in the 
afternoon he was drowsy and had a slight convulsion. The forward move- 
ment of the head was apparently somewhat restrained. On the 6th the 
symptoms had begun to abate, and in about one week from the commence- 
ment of the attack his health was fully restored. 

A boy aged six was well till the second week in May, 1872, when he 
became feverish and complained of headache. At my first visit, on May 
14th, he still had headache, with a pulse of 112. The pupils were sensitive 
to light, but the right pupil was larger than the left. The bromide and iodide 
of potassium were prescribed, with moderate counter-irritation behind the 
ears. The headache and fever in a few days abated, the equality of the 
pupils was restored, and within a little more than one week from the com- 
mencement of the disease he fully recovered. 

These cases occurred when the epidemic of 1872 was at its height; but 
if the symptoms are so mild and the duration of the disease short as in these 
two cases, the diagnosis must sometimes be doubtful. Observers in different 
epidemics report similar cases, and as the symptoms, so far as they appeared 
in my patients, seemed charcteristic, I have not hesitated to regard them as 
genuine but aborted cases. On such patients the epidemic influence acts so 
feebly or their ability to resist it is so great that they escape with a short and 
trivial ailment. 

Occasionally also during the progress of an epidemic we meet patients 



MODE OF COMMENCEMENT. 479 

who present more or fewer of the characteristic symptoms, but in so mild a 
form that they are never seriously sick and never entirely lose their appetite, 
but the disease, instead of aborting, continues about the usual time. 

Thus, on January 4, 1873, I was called to a girl aged thirteen who had 
been seized with headache, followed by vomiting, in the last week in Decem- 
ber. During a period of six to eight weeks, or till nearly March 1st, she had 
the following symptoms : daily paroxysmal headache, often most severe in 
the forenoon ; neuralgic pain in the left hypochondrium, and sometimes in 
the epigastric region ; pulse and temperature sometimes nearly normal, and 
at other times accelerated and elevated, both with daily variations ; inequality 
of the pupils, the right being larger than the left during a portion of the 
sickness. The patient was never so ill as to keep the bed, usually sitting 
quietly during the day in a chair or reclining on a lounge, and she never 
fully lost her appetite. Quinine had no appreciable effect on the fever or 
paroxysms of pain. 

There can, in my opinion, be little doubt that this girl was affected by the 
epidemic, but so mildly that there was, for a considerable time, much uncer- 
tainty in the diagnosis. 

Cases like these, in which the disease is so feebly developed that the 
patient is never seriously sick, though unimportant pathologically, must be 
recognized in a treatise on cerebro-spinal fever. 

Mode of Commencement. — Cerebro-spinal fever rarely begins in the 
forenoon after a night of quiet and sound sleep. In the cases which I 
observed in the severe and fatal epidemic of 1872, and in the 36 cases of 
which I have records observed since 1872, the commencement was almost 
without exception between midday and midnight. The fact that this disease 
does not commence after the repose of night till several hours of the day 
have passed shows the propriety and need of enjoining a quiet and regular 
mode of life, free from excitement and with sufficient hours of sleep, dur- 
ing the time in which the epidemic is prevailing. 

The commencement is usually without premonitory stage and sudden 
— unlike, therefore, the beginning of other forms of meningitis, which come 
on gradually and are preceded by symptoms which, if rightly interpreted, 
direct attention to the cerebro-spinal system. Exceptionally certain premo- 
nitions occur for a few hours or days before the advent of the disease, such 
as languor, chilliness, etc. Mild cases more frequently begin gradually and 
with certain premonitions than severe cases. The ordinar}^ mode of com- 
mencement is as follows : The patient is seized with vomiting, headache, and 
perhaps a chill or chilliness, so that there is a sudden change from perfect 
health to a state of serious sickness. Rigor or chilliness is a common initial 
symptom, especially in adult patients. One patient, an adult female, had 
three or four chills of considerable severity in the commencement of the 
attack. Children often have clonic convulsions in place of the chill or imme- 
diately after it, partial or general, slight or severe. Stupor more or less pro- 
found, or less frequently delirium, succeeds. In the gravest cases semi-coma 
occurs within the first few hours, in which patients are with difficulty aroused, 
or profound coma, which, in spite of prompt and appropriate treatment, is 
speedily fatal. Those thus stricken down by the violent onset of the disease 
if aroused to consciousness complain of severe headache, with or without or 
alternating with equally severe neuralgic pains in some part of the trunk or in 
one of the extremities. The pain frequently shifts from one part to another. 
Among the early symptoms of cerebro-spinal fever are those which pertain 
to the eye. The pupils are dilated or less frequently contracted, and they 
respond feebly or not at all to light if the attack be severe or dangerous ; 
often they oscillate, and occasionally one is larger than the other. Vomiting 



480 CEREBROSPINAL FEVER. 

with little apparent nausea, and often projectile, is common in the commence- 
ment of cerebro-spinal fever. It occurred as an early symptom in 51 of 
56 cases observed by Dr. Sanderson. In 97 cases occurring in New York, 
most of them observed by myself, but a few of them related to me by the 
late Dr. John Gr. Sewall, vomiting occurred as an early symptom in 68 cases. 
Its absence on the first day was recorded in only 3 cases, while in the remain- 
ing 27 patients the records of the first day make no mention of its presence 
or absence. It was probably present in most of these 27 cases as one of the 
first symptoms. 

Since the epidemic of 1872, in examining patients, now numbering thirty- 
six, as has been already stated, I have made careful inquiry in regard to the 
mode of commencement, and with only two or three exceptions either the 
previous health had been good, or, if symptoms of ill-health antedated the 
cerebro-spinal fever, they were due to some ailment entirely distinct from this 
disease. In a boy four and a half years of age, living in Broadway, it was 
stated to me that the cerebro-spinal fever came on gradually with pains in the 
head and elsewhere : this case was mild throughout and the patient was never 
in imminent danger. In nearly all the cases, if the patients were at home and 
under observation, the exact moment of the beginning of the disease could 
be stated. Thus, a man aged twenty-eight returned from his work at mid- 
day, April 23, 1883, in good health and cheerful, ate a hearty meal at twelve 
M., and at one P. M. had a chill, with intense headache and severe vomiting. 
Minute red points appeared on his face after vomiting, from capillary extrav- 
asations. In this case the interesting fact was observed of a cessation of 
the symptoms, so that on the 24th and 25th, being free from pain, he went 
to Brooklyn. On the 26th, however, the symptoms returned. He had pains 
in the head, back, and extremities, and was seriously sick. Occasional remis- 
sions, so that very grave symptoms become mild for a time and then return 
in full severity, as well as distinct intermissions, as in this case, have been fre- 
quently noticed by observers in different epidemics. A little girl, previously 
entirely well, was slightly punished on June 11, 1882 ; immediately she 
vomited and seemed quite sick ; by kind nursing on the part of the mother 
she became better, so that on the 12th she had some appetite and went out. 
On the 13th cerebro-spinal fever began, with a temperature of 103° F., and 
its course was tedious. A robust girl, aged thirteen, vivacious and cheer- 
ful, went as usual in the morning to one of the public schools entirely well. 
Before the school was dismissed she returned home crying on account of 
dizziness and violent pain in the top of her head, in her knees, and in the 
calves of the legs. The case was attended by Prof. Alonzo Clark, Prof. 
Knapp, and myself, and was fatal after four and a half weeks. A boy aged 
ten returned from another public school in a similar manner, having gone 
to it in the morning in apparently perfect health. 

We may therefore summarize as follows the symptoms which commonly 
attend the commencement of cerebro-spinal fever : violent pain in some part 
of the head, and sometimes also in the trunk or limbs, vomiting, a chill or 
chilliness, clonic convulsions, dizziness, dilated, sluggish, or altered pupils, 
fever of greater or less intensity according to the severity of the attack, heat 
of head, and in most patients heat of the surface generally. If the disease 
be of a severe and dangerous type, these symptoms are frequently followed 
within a few hours by delirium, semi-coma, or coma. 

Nervous System. — Since in cerebro-spinal fever extensive and severe 
inflammation of the cerebral and spinal meninges occurs, with more or less 
congestion of the brain and spinal cord — lesions which we will consider here- 
after — we should expect that this disease would be attended by severe and 
dangerous symptoms, inasmuch as the cerebro-spinal axis exerts such a con- 



MODE OF COMMENCEMENT. 481 

trolling influence upon the functions of the bod}'. Also we should expect 
that the sjmiptoms would vary according to the portion of the meninges 
which happens to be most severely inflamed. There is, indeed, variation in 
symptoms according to the extent and intensity of the meningitis and the 
degree in which the cerebro-spinal axis is congested or implicated, but certain 
symptoms occur in all or nearly all cases, and as they are characteristic they 
render diagnosis easy. 

Pain, already described as an initial symptom, continues during the acute 
period of the malady. It is ordinarily severe, eliciting moans from the 
suiferer, but its intensity varies in diff'erent patients. Its most frequent seat 
is. the head, and the location of the cephalalgia varies in diff'erent patients and 
in the same patient at diff'erent times. One refers it to the top of the head, 
another to the occiput, and another to the frontal region, and the same patient 
at different times may complain of all these parts. The pain is described as 
sharp, lancinating, or boring. It is also common in the neck, especially in 
the nucha, the epigastrium, the umbilical and lumbar regions, along the spine 
(rachialgia), and in the extremities, where it shifts from one part to another. 
It is more common and persistent in the head and along the spine than else- 
where. The patient, if old enough to speak and not delirious or too stupid, 
often exclaims, - Oh my head !" from the intensity of his suff"ering, but after 
some moments complains equally of pain in some other part, while perhaps 
the headache has cea.sed or is milder. In a few instances the headache is 
absent or is slight and transient, while the pain is severe elsewhere. After 
some days the pain begins to abate, and by the close of the second week is 
much less pronounced than previously. Vertigo occurs with the headache, 
so that the patient reels in attempting to stand or walk. I have stated above 
that vertigo may be a prominent initial symptom, as in the girl of thirteen 
years who suddenly became sick in the public school which she was attend- 
ing, and reached her home with difl&culty on account of the headache and 
dizziness. Contributing to the unsteadiness of the muscular movements is a 
notable loss of flesh and strength, which occurs early and increases. 

The state of the patient's mind is interesting. It is well expressed in 
ordinary cases by the term apathy or indifference, and between this mental 
state and coma on the one hand and acute delirium on the other there is 
every grade of mental disturbance. Some patients seem totally unconscious 
of the words or presence of those around them, when it subsequently 
appears that they understood what was said or done. Delirium is not infre- 
quent, especially in the older children and in adults. Its form is various, 
most frequently quiet or passive, but occasionally maniacal, so that forcible 
restraint is required. It sometimes resembles intoxication or hysteria, or it 
may appear as a simple delusion in regard to certain subjects. Thus, one 
of my patients, a boy of five years, appeared for the most part rational, 
protruding his tongue when requested, and ordinarily answering questions 
correctly ; but he constantly mistook his mother — who was always at his 
bedside — for another person. Severe active delirium is commonly preceded 
by intense headache. In favorable cases the delirium is usually short, but 
in the unfavorable it often continues with little abatement till coma super- 
venes. 

On account of the pain and the disordered state of the mind patients 
seldom remain quiet in bed, unless they are comatose or the disease be mild 
or so far advanced that muscular movements are difficult from weakness. 
In severe cases they are ordinarily quiet for a few moments, as if slumbering, 
and then, aroused by the pain, they roll or toss from one part of the bed to 
another. One of my patients, a boy of five years, repeatedly made the entire 
circuit of the bed during the spells of restlessness. In mild cases or cases 
31 



482 CEREBROSPINAL FEVER. 

attended by less headache or mental disturbance patients are quiet, usually 
with their eyes closed unless when disturbed. 

Hyperaesthesia of the surface is another common symptom. Few patients, 
not comatose, are free from it during the first weeks, and it materially increases 
the suifering. Friction upon the surface, and even slight pressure with the 
fingers upon certain parts, extort cries. Gently separating the eyelids for the 
purpose of inspecting the eyes, and moving the limbs or changing the position 
of the head, evidently increase the suifering and are resisted. I have some- 
times heard such expressions of suffering from slowly introducing the ther- 
mometer into the rectum that I was led to believe that the anal and perhaps 
rectal surfaces were hypersensitive. The hyperassthesia has diagnostic value, 
for there is no disease with which cerebro-spinal fever is likely to be con- 
founded in which it is so great. It is due to the spinal meningitis, and is 
appreciable even in a state of semi-coma. The headache and hyperaesthesia 
fluctuate greatly in the course of the disease, and the former sometimes recurs 
at times, especially from mental excitement or from an afflux of blood to the 
brain from physical exertion, for months after the health is otherwise fully 
restored. 

Some contraction of certain muscles or groups of muscles is present in 
all typical cases. In a small proportion of patients it is absent or is not a 
prominent symptom — to wit, in those in whom the encephalon is mainly 
involved, the spinal cord and meninges being but slightly affected or not at 
all. This contraction is most marked in the muscles of the nucha, causing 
retraction of the head, but it is also common in the posterior muscles of the 
trunk, causing opisthotonos, and in less degree in those of the abdomen and 
lower extremities, and hence the flexed position of the thighs and legs, in 
which patients obtain most relief. The muscular contraction is not an initial 
symptom. I have ordinarily first observed it about the close of the second 
day, but sometimes as early as the close of the first day, and in other 
instances not till the close of the third day. Attempts to overcome the 
rigidity, as by bringing forward the head, are very painful and cause the 
patient to resist. In young children having a mild form of the fever, with 
little retraction of the head, the rigidity is sometimes not easily detected. 
I have been able in such cases to satisfy myself and the friends of its 
presence by placing the child in an upright position, as on the lap of the 
mother, and observing the difiiculty with which the head is brought forward 
on presenting to the patient a tumberful of cold water, which is craved on 
account of the thirst. The usual position of the patient in bed in a typical 
or marked case is with the head thrown back, the thighs and legs flexed, with 
or without forward arching of the spine. The muscular contraction and 
rigidity continue from three to five weeks, more or less, and abate gradually ; 
occasionally they continue much longer. Through the kindness of Dr. Henry 
Griswold I was allowed to see an infant of seven months in the tenth week 
of the disease. It was still very fretful, and exhibited decided prominence 
of the anterior fontanel, probably from intracranial serous effusion, and marked 
rigidity of the muscles of the nucha, with retraction of the head. 

Paralysis is another occasional symptom, but complete paralysis of any 
muscle or group of muscles is less frequent than one would suppose from 
the nature of the malady. It may occur early, but is sometimes a late 
symptom. It may be limited to one or two of the limbs, as the legs or an 
arm and a leg, or it may be more general. In a case occurring in Roosevelt 
Hospital and published in the Neiv York Medical Record for October 10, 
1878, the patient, a boy of ten years, was unable to move his legs one hour 
after the commencement of the disease. This sudden development of para- 
plegia in the commencement of cerebro-spinal fever resembled that of infan- 



MODE OF COMMENCEMENT. 



483 



tile paralysis, and was probably due to the same cause — to wit, active 
inflammatory congestion of the anterior cornua of the spinal column. The 
sudden and complete loss of speech which occurs in certain cases, when con- 
sciousness is retained and the vocal organs are in their normal state, seems 
to be due to the fact that the portion of the brain which controls the func- 
tion of speech is acutely congested or is the seat of effusion. Thus, in 
June, 1882, a girl of three years whom I attended lost her speech on the 
second day of cerebro-spinal fever, and she was unable to articulate even 
the simplest word for two and a half months. Finally, she began to utter 
slowly and with difficulty the easiest monosyllables ; and after the lapse of 
more than a year her speech was slow and lisping, her hands were tremulous 
and unsteady, she was easily fatigued, and cried often from oversensitiveness. 
During the long period of speechlessness she daily made efforts to talk, but 
without uttering a sound. Strabismus, to which we will allude hereafter in 
treating of the eye, is a common symptom, either transient or protracted, 
due to paralysis of certain of the motor muscles of the eye. 

Paralysis of more or fewer muscles has been noticed and recorded by 
many observers in this country and in Europe. Dr. Law observed a patient 
in the epidemic of 1865 in Dublin who could move neither arms nor legs, 
and Wunderlich saw one who had paralysis of both lower extremities and 
of a considerable part of the trunk. As this symptom is due to the 
inflammatory process of the cerebro-spinal axis, it usually disappears in a 
few weeks as the inflammation abates and absorption of the inflammatory 
products occurs; but it may be more protracted. In Wunderlich's case 
there was only partial recovery from the paralysis after the lapse of five 
months. 

Clonic convulsions have already been alluded to among the early symp- 
toms of the attack. They indicate a grave form of the disease, and are 



Fig. 30. 




not infrequent in young children, in whom they appear to occur in place 
of the chill which is common in those of a more advanced age. The 
eclamptic attack may be short and not repeated, or it may be protracted, or 
return again and again when the medicines which controf it are suspended. 
Under such circumstances it is likely to end in profound coma, and is, of 
course, a symptom of great gravity. Thus, an infant of seven months had 
unilateral eclamptic attacks daily during the first week of the attack. The 
mother informed me that the convulsions seldom lasted longer than three 
minutes, and that the intervals between them were short. The child 



484 CEREBROSPINAL FEVER. 

recovered with loss of sight from the cerebro-spinal fever, but still after the 
lapse of a year, when I examined him, had symptoms which were apparent- 
ly due to hydrocephalus. Another infant of eleven months had clonic con- 
vulsions nearly constantly during the first twenty-four hours, but with 
occasional brief intermissions. On the following day he was in profound 
coma and apparently dying, with a temperature of 105° F. To my aston- 
ishment, he gradually emerged from the state of unconsciousness, and after a 
week was able to sit in his cradle long enough to take drinks. 

Occasionally eclampsia does not occur in the first days, but in the second 
or third week, when it is usually accompanied by an increase of other symp- 
toms, due to a recrudescence of the disease. A female infant aged eleven 
months, treated by me in 1882, had been sick one week when, during an 
increase in the febrile movement, she had one eclamptic seizure. Her recov- 
ery, though slow, was complete. A boy aged eleven and a half years, whose 
attack began with a chill, violent headache, and fever, and whom I visited 
frequently, died on the fourth day. Clonic convulsions did not occur in his 
case until within twenty-four hours of his death, when he had six seizures, 
which ended in coma. 

Though adult patients are much less liable to eclampsia than children, 
they are not entirely exempt. A male patient aged twenty-eight years, 
whom I saw in consultation, had a single clonic convulsion lasting ten to 
fifteen minutes on the third day of his illness. In five weeks he had fully 
recovered, except that his headache returned upon any excitement. Even 
drinking a cup of beer caused it. Clonic convulsions are, however, much less 
common than the tonic muscular contraction and rigidity already alluded to. 
This occurs to a greater or less extent in nearly all cases, and is a symptom 
of diagnostic value, the rigidity often extending to the muscles of the extrem- 
ities. Thus, in a child aged three years who had no eclampsia the tonic con- 
traction of the muscles of the extremities did not relax till after the twelfth day. 

Choreic or choreiform movements are occasionally observed. I do not 
refer to the tremulousness which sometimes occurs from weakness or as a 
premonition of eclampsia, but to a movement which has the character of 
true chorea. An infant aged ten months began to have choreic movements 
during the acute stage of the disease, most marked in the upper extremities 
and ceasing in sleep. They continued during the remainder of the life of the 
child, death occurring ten months subsequently from diphtheria. Rarely a 
choreiform movement of the eyes is also observed — a lateral movement from 
right to left and from left to right. I have seen from recollection two such 
cases. 

Drowsiness, already spoken of, is a common symptom, and it exists in all 
grades from slight stupor to profound coma. In some patients it is present 
from the first hour, while in others it occurs after a period of restlessness or 
delirium or it alternates with it. Stupor more or less profound is common 
after the attack of eclampsia or the chill. That it is a frequent symptom in 
severe cases receives ready explanation from the state of the brain and its 
meninges, for the exudation which occurs upon the surface of the brain and 
the serous efl'usion within the ventricles are sufficient to cause it by compress- 
ing the cerebral substance. It is surprising in some cases how profound the 
stupor may be — a state, indeed, of coma, and yet the patient gradually 
emerges from it and recovers. In the epidemic of 1872, in New York 
City, when the malady was new with us, many physicians predicted cer- 
tain death, and employed remedies without expectation of any benefit 
on account of the apparently hopeless state of patients, who seemed to 
be in profound coma, and yet not a few of them gradually and fully 
recovered. 



MODE OF COMMEXCEMENT. 485 

Digestive System. — Vomiting, which is the most prominent symptom refer- 
able to the digestive system, has ah'eady been mentioned. Occurring early in 
the disease, it may cease in a few hours or not till after several days, and often 
it returns during the periods of recrudescence which are common in the prog- 
ress of the fever. It occurs with little effort and without previous nausea or 
with little nausea, as is usual when it has a cerebral origin. It does not differ 
as a symptom from the vomiting which is so common in other forms of men- 
ingitis. The substance vomited consists of the ingesta and the secretions, as 
mucus and bile. Having a similar origin is a sensation of faintness or depres- 
sion, referred to the epigastrium. 

The appetite is usually impaired or lost during the active period of the 
attack, and it is not fully restored till convalescence is well advanced. 
Occasionally considerable nutriment is taken, and with apparent relish, as 
by one of my patients, twenty-eight years of age, who always had some 
appetite. Ordinarily, on account of repeated vomitings, constant febrile 
movements, impaired appetite and digestion, patients progressively lose 
flesh and strength, so that in protracted cases emaciation is always a 
prominent symptom, and is often extreme. Much emaciation and loss of 
strength, which attend many cases after the lapse of several weeks, greatly 
diminish the chances of a favorable termination. Thirst, already referred to, 
and constipation are common in this as in other forms of meningitis, but 
retraction of the abdomen is not a notable symptom, except in protracted and 
greatly-wasted cases. The diarrhoea which is occasionally present in cerebro- 
spinal fever in the summer months must be regarded as a distinct disease 
and a complication. The tongue and the buccal and faucial surfaces present 
nothing, unusual in their appearance. It is seldom, even in the most pro- 
tracted and emaciated cases, that the sordes and dry and brownish fur occur 
which are so common in typhus and typhoid fevers. The tongue is usually 
moist and but slightly furred. 

I have seen in consultation two patients tliat perished early with inability 
to swallow as the prominent symptom, attended in both by an abundant secre- 
tion upon the faucial surface, without any redness, swelling, or other evidence 
of inflammation. The early death of these young children, whose ages were 
ten months and two years, rendered the diagnosis less certain than in most 
other patients, but the attending physician as well as myself diagnosticated 
cerebro-spinal fever with suddenly developed paralysis of the muscles of 
deglutition, so that no nutriment could be taken. If our understanding of 
these interesting cases is correct, the paralysis was caused by lesion of that 
portion of the medulla oblongata which controls the function of deglutition, 
or else by injury of the intracranial portions of the nerves which supply the 
muscles concerned in this act. The following were the cases in question : 

, male, two years of age, became feverish and dull, but without 

vomiting, on October 22, 1882; axillary temperature, 102° F. On the fol- 
lowing day inability to swallow occurred, and the muscles of deglutition 
appeared totally inactive. Death occurred on the third day, suddenly and 
apparently easily, as if from arrested function of important nerves, especially 
the pneumogastric. The abundant secretion of thin mucus or transudation 
of serum covering the faucial surface, and reaccumulating as soon as removed 
without any notable change in the appearance of the fauces, was remarkable. 
The physician in attendance, who for more than thirty years had had a large 
city practice, had seen no similar case, nor had I at the time. 

Soon afterward the second case occurred. An infant of ten months, with- 
out cough or embarrassment of respiration or faucial redness or swelling, lost 
the power of deglutition soon after the commencement of the supposed cere- 
bro-spinal fever, so that in the attempts to swallow the drinks entered the 



486 CEREBROSPINAL FEVER. 

larynx, and the secretion or exudation was abundant, as in the other case. 
Death occurred in forty-eight hours. The rectal temperature was only 101° F. 

In another case, which was ultimately fatal and in which the diagnosis of 
cerebro-spinal fever was certain, a robust girl, aged twelve, suddenly lost the 
power of deglutition at one time during her sickness, although she was 
entirely conscious and repeatedly endeavored to swallow. The ability to 
swallow returned in a few days. 

Pulse, — This is usually accelerated, and the more severe and danger- 
ous the attack the more rapid is the heart's action, except occasionally in the 
comatose state, when, probably in consequence of compression of the brain 
from an abundant exudation, the pulse may be subnormal. Thus, in one of 
my patients, an adult, the pulse fell to 40 per minute, and in two others to 
between 60 and 70 per minute. With the exception of these three, the pulse 
in all cases which I have observed, so far as 1 recollect, has varied from the 
normal number of beats per minute to such frequency that it was difficult to 
count it. As death draws near the pulse ordinarily becomes more frequent 
and feeble. Intermissions in the pulse do not seem to be as common as in 
other forms of meningitis, but marked variations in its frequency during 
different hours of the day and on consecutive days constitute a conspicuous 
symptom. Thus, in a case which was fatal in the fifth week consecutive 
enumerations of the pulse in the acute stage were as follows: 128, 120, 88, 
130, 84, 112. 

Temperature. — Some of the older writers before the days of clinical ther- 
mometry stated that the temperature is not increased. North remarked as 
follows : " Cases occur, it is true, in which the temperature is increased above 
the natural standard, but these are rare ;" and Foot and Gallop make similar 
statements. Some recent writers have held the same opinion. Thus, Lidell 
wrote as follows in a treatise bearing the date of 1873 : " Febrile symptoms 
do not necessarily belong to epidemic cerebro-spinal meningitis as a substan- 
tive disease, for it may, and not unfrequently does, occur without exhibiting 
any such symptoms." We should naturally expect that meningitis, accom- 
panied as it is by active congestion of the brain and spinal cord, would pro- 
duce more or less fever, and in eighty-six cases which I examined by the 
thermometer I found elevation of temperature in every case during the acute 
stage, except in the beginning of the attack in two instances. In a young 
man aged twenty-eight years who had severe headache and seemed seriously 
sick the thermometer under the tongue showed no rise of temperature on the 
first and second days, but on the third day it was at 100° F., and it remained 
elevated till his death on the thirteenth day. The second case was that of a 
young woman whom I saw in consultation, and who at the time of my visit 
had fever, but had had none previously, according to the statement of the 
attending physician. 

In the 87 cases which I examined the heat of the surface occasionally 
did not seem above normal to the touch, and now and then the thermometer, 
applied in the axilla or groin, did not indicate fever, but the rectal temper- 
ature was always elevated above that of health after the disease was fully 
established. The temperature fluctuated from day to day and in different 
hours of the same day, but there was no exception to the rule that it was 
above the normal during the active stage of the malady after the "first 
few days. Sometimes the elevation of temperature was slight, as in a female 
patient forty-seven years of age, in whom the thermometer showed no eleva- 
tion of temperature when it was placed in the mouth and axilla, but on 
introducing it into the rectum it rose to to 99-2° F. In the case of a young 
lady attended by me in 1890, having a very asthenic and fatal form of 
cerebro-spinal fever, accompanied by great prostration, a brown and dry 



MODE OF COMMENCEMENT. 487 

tongue, and delirium, the temperature under the tongue was subnormal 
during the first two or three days, but was afterward above normal. 

The highest temperature which I have thus far observed was 107|-° F.,. 
in a child aged two years. This was in the commencement of the attack. 
Subsequently it fell a little, but rose again on the third day to 107°, when 
she died. In two other cases the temperature was 106° F. on the first day, 
and it did not afterward reach so high an elevation. One of these died on 
the ninth day, and the other in the ninth week. The next highest temperature 
was 1054° F., also on the first day, in an infant aged eight months, who died 
on the ninth day. The first and last of these cases occurred in an old wooden 
tenement-house in the suburbs of the city and upon an elevated outcropping 
of rock. The highest temperature in any case in New York City which has 
come to my notice was observed in a male patient aged twenty-eight years 
who had active delirium, and died on the fifth day in Roosevelt Hospital. 
The temperature on the last day, taken four times, was as follows : 102^°, 
1061°, and, when the pulse had become imperceptible, 109° and 107f° F. 
AYunderlich has recorded a temperature of 110° F. in one or two cases, but so 
great an elevation must be very rare, and is of course prognostic of an unfa- 
vorable ending. 

The external temperature undergoes still greater fluctuations tlian the 
internal, rising above and falling below the normal standard several times in 
the course of the same day. Similar fluctuations occur in other forms of 
meningitis, but they are, according to my experience, less pronounced than 
in cerebro-spinal fever, especially as I observed them in the epidemic of 
1872. Perhaps since that epidemic they have been less marked in the cases 
occurring in this city. The more grave the attack in those not comatose the 
greater these variations. The following is a common example of these sudden 
thermometric changes, occurring in a child of two years. The internal tem- 
perature varied from 101° to 104i° F. as the extremes, while that of the 
fingers and hands at the first examination was 90 5°, at the second 90°, at the 
third 103°, and at the fourth 83°. Hence at the third examination the tem- 
perature of the extremities had risen 13°, so as nearly to equal that of the 
blood, and at the fourth examination it had fallen 20°. The patient recov- 
ered. These great and sudden variations in the pulse and the internal and 
external temperature have considerable diagnostic value in obscure and 
doubtful cases. 

Respiratory System. — This system is not notably involved in ordinary 
cases. Intermittent, sighing, or irregular respiration appears to be less 
frequent than in tubercular meningitis, but it does occur. In most patients 
the respiration is quiet, but somewhat accelerated, and without any marked 
disturbance in its rhythm. In thirty-one observations in children who had 
no complication, I found the average respirations 42 per minute, while the 
average pulse was 137. Therefore the respiration, as compared with the 
pulse, was proportionately more frequent than in health, due perhaps to the 
fact that certain muscles concerned in respiration, as the abdominal, are em- 
barrassed in their movements by tonic contraction. 

Various observers in different epidemics have recorded an unusual preva- 
lence of croupous pneumonia occurring simultaneously with cerebro-spinal 
fever. Bascome in his history of epidemics stated that " epidemic encephal- 
itis and malignant pneumonias prevailed in Germany in the sixteenth cen- 
tury " (Webber). Webber in his prize essay describes a variety of cerebro- 
spinal fever which he designates pneumonic, in which the cerebro-spinal axis 
is involved but slightly or not at all, and the brunt of the disease falls upon 
the respiratory organs. According to him, in certain epidemics the pneu- 
monic form has been common and in others infrequent. This fact is interest- 



488 CEREBROSPINAL FEVER. 

ing taken in connection with the examination of the microbes of croupous 
pneumonia and cerebro-spinal fever, as detailed in our remarks under the 
head of etiology. 

Cutaneous Surface. — The features may be pallid, of normal appearance, 
or flushed in the first days of the disease, but in advanced cases they are 
pallid, as is the skin generally. A circumscribed patch of deep congestion 
often appears, as in sporadic meningitis, upon some part of them, as the 
forehead, cheek, or an ear, and after a short time disappears. The hyper- 
semic streak, the tache cerebrale of Trousseau, produced by drawing the fin- 
ger firmly across the surface, also appears as in other forms of meningitis if 
the temperature of the surface be not too much reduced. 

The following are the abnormal appearances of the skin most frequently 
observed: 1. Papilliform elevations, the so-called goose-skin, due to contrac- 
tions of the muscular fibres of the corium. This is not uncommon in the 
first weeks. 2. iV dusky mottling, also common in the first and second 
weeks in grave cases, and most marked when the temperature is reduced. 
3. Numerous minute red points over a large part of the surface, bluish spots 
a few lines in diameter, due to extravasation of blood under the cuticle, 
resembling bruises in appearance, and large patches of the same color an 
inch or more in diameter, less common than the others, of irregular shape as 
well as size, and usually not more than two or three upon a patient. These 
last resemble bruises, and they may sometimes be such, received during the 
times of restlessness; but ordinarily extravasations of this kind result 
entirely from the altered state of the blood. In New York in the epidemic 
of 1872 they were common, but since this epidemic, in the thirty-six cases 
which I have observed, I have rarely seen either the reddish points or the 
extravasations of blood. They were probably common in the epidemics in 
the first part of this century in this country, since the disease was desig- 
nated by the name " spotted fever " by the American physicians who wrote 
upon it at that time. That they are unusual in the European epidemics at 
the present time we infer from the fact that Von Ziemssen expresses sur- 
prise that the disease should ever have been designated in America by such 
a title. 4. Herpes. This is common. It sometimes occurs as early as the 
second or third day, but in other instances not till toward the close of the 
first week or in the second. The number of herpetic eruptions varies from 
six or eight to clusters as large as or larger than the hand. This cutaneous 
disease evidently has a nervous origin, its vesicles occurring in most 
instances on those parts of the surface which are supplied by branches of 
the fifth pair of nerves. Its most common seat is upon the lips, but occa- 
sionally it appears upon the cheek, upon and around the ears, and upon the 
scalp. Erythema and roseola, both transient skin eruptions, occasionally 
appear, and in one instance in my practice erysipelas occurred. During the 
first days the skin is frequently dry ; afterward perspirations are not unusual, 
and free perspirations sometimes occur, especially about the head, face, and neck. 

Urinary Organs. — In other forms of meningitis it is well known that the 
quantity of urine excreted is usually diminished, but in this disease it is 
normal, and it may be more than normal. Polyuria has been noticed in dif- 
ferent cases by various observers. Mosler observed a boy aged seven years 
who had an excessive secretion of urine, which dated back to an attack of 
cerebro-spinal fever in his third year. The polyuria is probably due to 
injury of the nervous centre, since physiological experiment has demon- 
strated that irritation of the central end of the vagus, of certain parts of the 
cerebellum, and of the walls of the fourth ventricle sometimes produces this 
effect. The urine occasionally contains a moderate amount of albumen, and 
in exceptional instances cylindrical casts and blood-corpuscles. 



MODE OF COMMENCEMENT. 489 

Arthritic inflammation, apparent!}^ of a rheumatic character, has been 
occasionally observed. It is commonly slight, producing merely an oedema- 
tous appearance around one or more joints. Thus in one case which came 
under my notice, and which was subsequently fatal, the parents, who were 
poor, and were therefore without medical advice till the case was somewhat 
advanced, had already diagnosticated rheumatism on account of the puffiness 
which they had noticed around one of the wrists. 

The Special Senses. — Taste and smell are rarely affected, so far as is 
known, but it is possible that they are sometimes perverted, or even tempo- 
rarily lost, during the time of greatest stupor. In one case which I saw the 
sense of smell was entirely lost in one nostril, and I do not know whether it 
was ever fully restored. 

The affections of the eye and ear are important and of frequent occurrence. 
Strabismus is common. It may occur at any period of the fever, continuing 
a few hours or several days, and it may appear and disappear several times 
before convalescence is established : occasionally it continues several weeks, 
after which the parallelism of the eyes is gradually and fully restored. In 
other instances it is permanent. 

Changes in the pupils are among the first and most noticeable of the 
initial symptoms, as I have already stated in describing the mode of com- 
mencement. These are dilatation, less frequently contraction, oscillation, 
inequality of size, feeble response to light, etc. Most patients present one 
or more of these abnormalities of the pupils, and they continue during the 
first and second weeks, and gradually abate if the course of the disease be 
favorable. Inflammatory hypersemia of the conjunctiva often occurs. It 
begins early, and now and then the conjunctivitis is so intense that consider- 
able tumefaction of the lids results, with a free muco-purulent secretion. The 
false diagnosis has indeed been made of purulent ophthalmia in cases in which 
this affection of the lids was early and severe. But such intense inflamma- 
tion is quite exceptional. More frequently there is a uniform diffused redness 
of the conjunctiva, not so dusky as in typhus, and the injected vessels cannot 
be so readily distinguished as in that disease. 

In certain cases almost the whole eye (all, indeed, of the important con- 
stituents) becomes inflamed; the media grow cloudy, the iris discolored, and 
the pupils uneven and filled up with fibrinous exudation. The deep struc- 
tures of the eye cannot, therefore, be readily explored by the ophthalmo- 
scope, but they are observed to be adherent to each other and covered by 
inflammatory exudation. They present a dusky-red or even a dark color 
when the inflammation is recent. Exceptionally the cornea ulcerates and 
the eye bursts, with the loss of more or less of the liquids and shrinking 
of the eye. " But ordinarily no ulceration occurs, and as the patient con- 
valesces the oedema of the lids, the hypersemia of the conjunctiva, the cloud- 
iness of the cornea and of the humors gradually abate and the exudation 
in the pupils is absorbed. The iris bulges forward, and the deep tissues of 
the eye, viewed through the vitreous humor, which before had a dusky-red 
color from hypersemia, now present a dull-white color." The lens itself, at 
first transparent, after a while becomes cataractous. Sight is lost totally and 
for ever. 

If the patient live, the volume of the eye diminishes, as the inflammation 
abates, to less than the normal size, even when there has been no rupture 
and escape of the fluids, and divergent strabismus is likely to occur. Prof. 
Knapp, whose description of the eye I have for the most part followed, says : 
" The nature of the eye affection is a purulent choroiditis, probably meta- 
static." Fortunately, so general and destructive an inflammation of the eye 
as has been described above is comparatively rare. On the other hand, con- 



490 CEREBROSPINAL FEVER. 

junctivitis of greater or less severity, and hyperaemia of the optic disc, con- 
sequent upon the brain disease, are not unusual, but they subside, leaving the 
function of the organ unimpaired. " In some cases incurable blindness is 
noticed under the ophthalmoscope picture of optic nerve-atrophy, probably 
the sequence of choked disc " (Knapp). 

Inflammation of the middle ear, of a mild grade and subsiding without 
impairment of hearing, is common. The membrana tympani during its con- 
tinuance presents a dull-yellowish, and in places a reddish, hue. Occasionally 
a more severe otitis media occurs, ending in suppuration, perforation of the 
membrana tympani, and otorrhoea, which ceases after a variable time. But 
otitis media is not the most severe of the affections of the organs of hearing. 
Certain patients lose their hearing entirely, and never regain it, and that, too, 
with little otalgia, otorrhoea, or other local symptoms by which so grave a 
result can be prognosticated. This loss of hearing does not occur at the 
same period of the disease in all cases. Some of those who become deaf are 
able to hear as they emerge from the stupor of the disease, but lose this 
function during convalescence, while the majority are observed to be deaf as 
soon as the stupor abates and full consciousness returns. 

Two important facts have been observed in reference to the loss of hear- 
ing in these patients — to wit, it is bilateral and complete. When first 
observed it is in some, as stated above, complete, but in others partial, and 
when partial it gradually increases till after some days or weeks, when it 
becomes complete. I have the records of 10 cases of this loss of hearing, 
most of them occurring in my own practice in the epidemic of 1872, but a 
few or them detailed to me by the physicians who observed them in the same 
epidemic. According to these statistics, about 1 in every 10 patients became 
deaf, but in the milder form of cerebro-spinal meningitis which has prevailed 
since 1872 the proportionate number thus affected has been less among my 
patients, and the same may be said in reference to the loss of sight : 1 of 
the 10 cases was a young lady, but the rest were children under the age of 
ten years. Prof. Knapp has examined 31 cases. " In all," says he, " the 
deafness was bilateral, and, with 2 exceptions of faint perceptions of sound, 
complete. Among the 29 cases of total deafness there is only 1 who seemed 
to give some evidence of hearing afterward." The same author has recently 
informed me that further experience has confirmed his previous statement, 
that while the blindness produced by cerebro-spinal fever is in the majority 
of cases monolateral, but one case had come to his notice in which the deaf- 
ness was on one side only. 

One theory attributes the loss of hearing to inflammatory lesions either 
at the centre of audition within the brain, or in the course of the auditory 
nerves before they enter the auditory foramina. The other theory, which 
is the better established of the two and must be accepted, attributes the loss 
of hearing to inflammatory disease of the ear, and especially of the labyrinth. 

Symptoms of Endemic or Naturalized Cerebro-Spinal Fever. — 
The numerous monographs on this disease which have appeared during the 
last few years relate to its epidemic form, and no published observations, so 
far as I am aware, describe the character or symptoms which it presents or 
the changes which it undergoes when it occurs as an endemic or naturalized 
disease. The endemic disease must, of course, be observed in the cities or 
populous towns, for there is no rural locality, so far as I am aware, in which 
this disease is permanently established. In New York the naturalized dis- 
ease appears to be accompanied by a less profound blood-change than occurs 
in epidemic cases. Although every year seeing a considerable number of 
cases. I have not in the last ten years seen one with the livid spots upon 
the surface, due to subcutaneous extravasation of blood, which were so 



NATUBE. 491 

common in the epidemic of 1872, and which have been so common in 
epidemics both in this country and in Europe that the term " spotted fever " 
was applied to the malady. Occasionally petechias occur in severe cases of 
the naturalized disease. 

Nature. — The theory that cerebro-spinal fever is a local disease, occur- 
ring epidemically, was commonly held in the first part of this century, but 
is now discarded. Job Wilson in 1815 considered it a form of influenza, 
and could see no utility in drawing a distinction between spotted fever and 
influenza. We at the present time can see no resemblance between the two, 
except that both occur as epidemics. The theory that cerebro-spinal fever is 
a peculiar local disease occurring in epidemics is more plausible than that 
which holds that it is a form of influenza. Even Niemeyer says that it pre- 
sents no symptoms except such as are referable to the local afi'ection. But 
the evidence is strong that cerebro-spinal fever is a constitutional malady 
with the meningitis as a local manifestation, just like measles with its bron- 
chitis or scarlet fever with its pharyngitis. The abrupt and severe com- 
mencement, unlike that of those forms of meningitis which are known to be 
strictly local, and the early blood-change, as shown in certain cases by the 
appearance of the skin and extravasation under it, indicate a general disease. 
Constitutional diseases having prominent local symptoms and lesions are usu- 
ally regarded at first as local. It is only as time goes on and they are more 
thoroughly studied and understood, and clinical observations multiply, that 
their constitutional nature is recognized. 

The theory that cerebro-spinal fever is a form of typhus once had advo- 
cates, but it is now so generally discarded as untenable and absurd that it 
would be a waste of time to consider the facts which difi"erentiate the two mala- 
dies. Cerebro-spinal fever should therefore be considered as distinct from all 
other diseases, a malady sui generis, and in nosological writings it should be 
classified with those constitutional maladies which have specific causes. 

Although this disease ordinarily occurs in an epidemic form in localities 
widely separated from one another, and, after continuing a few weeks or 
months, totally disappears, perhaps never to return or not till after the lapse 
of years, nevertheless in localities it becomes established, so that it is proper 
to describe it as an endemic — a fact to which we have already referred as 
regards certain American cities. I do not know that it is endemic in any 
village or rural locality in this country. The large cities, with their promis- 
cuous population, foreign and native, their crowded tenement-houses, and 
their many sources of insalubrity, furnish in an eminent degree the condi- 
tions which are favorable for the development and perpetuation of the microbic 
diseases. Those diseases which in the present state of our knowledge we 
have reason to believe are caused by micro-organisms we should expect to 
prevail most where domiciles are crowded and filthy and systems are ener- 
vated by impure air, hardships, and privation. Hence in New York City, in 
the crowded quarters of the poor, cerebro-spinal fever, like diphtheria, is sel- 
dom or never absent. 

Deaths in New York from Cerehro- Spinal Fever. 



Number. 

1872 782 

1873 290 

1874 158 

1875 146 

1876 127 

1877 116 

1878 97 



Number, 

1880 170 

1881 461 

1882 238 

1883 223 

1884 210 

1885 202 

1886 223 



1879 108 i 1887 203 



492 CEREBROSPINAL FEVEE. 

It is seen that the greatest mortality was in the first year after the intro- 
duction of the disease into the city, after which the number of deaths 
gradually diminished, year by year, till 1878, when the lowest mortality 
was reached. After 1878 the mortality gradually increased till 1881, in 
which year the number of deaths was double that of any other year except 1872. 

The mortuary reports of Philadelphia likewise show that cerebro-spinal 
fever has remained in that city since its introduction in 1863, a period of 
twenty-five years, the annual deaths produced by it varying between 36, the 
minimum, in 1869 and 1870, and 384, the maximum, in 1864. In Provi- 
dence also, as appears from Dr. Snow's reports, cerebro-spinal fever has 
caused annually more or fewer deaths since 1871. Therefore, we repeat, 
this fact may be added to the sum of our knowledge of this disease, that 
once gaining a lodgment where the conditions are favorable for it, as in a 
large city, it may become established and remain an indefinite time. 

Anatomical Characters. — I have notes of the post-mortem appear- 
ances in 76 cases, published chiefly in British and American journals: 29 
died within the first three days, 28 between the third and twenty-first days, 
and the duration of the remaining 19 was unknown. These records furnish 
the data for the following remarks. 

The blood undergoes changes which are due in part to the inflammatory 
and in part to the constitutional and asthenic nature of the disease. The pro- 
portion of fibrin is increased in cases that are not speedily fatal, as it ordi- 
narily is in idiopathic inflammations. Analyses of the blood by Ames, 
Tourdes, and Maillot show a variable proportion of fibrin from three and 
four-tenths to more than six parts in one thousand. In sthenic cases accom- 
panied by a pretty general meningitis, cerebral and spinal, there is, after the 
fever has continued some days, the maximum amount of fibrin, while in the 
asthenic and suddenly fatal cases, with inflammation slight or in its com- 
mencement, the fibrin is but little increased. The most common abnormal 
appearance of the blood observed at autopsies is a dark color with unusual 
fluidity and the presence of dark soft clots. Exceptionally bubbles of gas 
have been observed in the large vessels and the cavities of the heart. An 
unusually dark color of the blood, small and soft dark clots, and the presence 
of gas-bubbles when only a few hours have elapsed after death indicate a 
malignant form of the disease, in which the blood is early and profoundly 
altered. In certain cases this fluid is not so changed as to attract attention 
from its appearance. The points or patches of extra vasated blood which are 
observed in and under the skin during life in some patients usually remain in 
the cadaver. When an incision is made through them the blood is seen to 
have been extravasated, not only in the layers of the skin, but also in the 
subcutaneous connective tissue. Extravasations of small extent are likewise 
sometimes observed upon and in thoracic and abdominal organs. 

In those who die after a sickness of a few hours or days — namely, in 
the stage of acute inflammatory congestion — the cranial sinuses are found 
engorged with blood and containing soft dark clots. The meninges envelop- 
ing the brain are also intensely hyperaemic in their entire extent in most 
cadavers, but in some cases the hypersemia is limited to a portion of the 
meninges, while other portions appear nearly normal. In those cases which 
end fatally within a few hours this hypergemia is ordinarily the only lesion 
of the meninges ; but if the case be more protracted serum and fibrin are 
soon exuded from the vessels into the meshes of the pia mater, and under- 
neath this membrane over the surface of the brain. Pus-cells also occur 
mixed with the fibrin, sometimes so few that they are discovered only with 
the microscope, but in other cases in such quantity as to be much in excess 
of the fibrin and to be readily detected by the naked eye. Pus, which in 



ANAT03IICAL CHARACTERS. 493 

these cases probably consists of white blood-corpuscles which have escaped 
with the fibrin from the meningeal vessels, often appears early in the attack. 
The arachnoid soon loses its transparency and polish, and presents a cloudy 
appearance over a greater or less extent of its surface. This cloudiness is 
usually greatest along the course of the vessels in the sulci and depressions 
and where the fibrinous exudation is greatest, but it occurs also in places 
where no such exudation is apparent to the naked eye. 

The exudation — serous, fibrinous, and purulent — occurs, as in other forms 
of meningitis, within the meshes of the pia mater, and underneath this mem- 
brane over the surface of the brain. The fibrin is raised from the surface of 
the brain with the meninges in making the autopsy. It is most abundant in 
the intergyral spaces, around the course of the vessels, over and around the 
optic commissure, pons Varolii, cerebellum, and medulla oblongata, and along 
the Sylvian fissures. It is most abundant in the depressions, where it some- 
times has the thickness of one-tenth to one-fourth of an inch, but it often 
extends over the convolutions so as to conceal them from view. 

Most other forms of meningitis have a local cause, and are therefore 
limited to a small extent of the meninges — as, for example, meningitis from 
tubercles or caries of the petrous portion of the temporal bone, in both of 
which it is commonly limited to the base of the brain ; or from accidents, 
when the meningitis commonly occurs upon the side or summit of the brain. 
The meningitis of cerebro-spinal fever, on the other hand, having a general 
or constitutional cause, occurs with nearly equal frequency upon all parts of 
the meningeal surface, except that it is perhaps most severe in the depres- 
sions, where the vascular supply is greatest. In cases of great severity the 
inflammatory exudation, fibrinous or purulent, or both, covers nearly or quite 
the entire surface of the brain. 

In those who die at an early stage of the attack the vessels of the brain, 
like those of the meninges, are hypersemic, so that numerous " puncta vas- 
culosa " appear upon its incised surface. At a later period this hypersemia, 
like that of the meninges, may disappear. If there be much eff"usion of 
serum within the ventricles and over the surface of the brain, the convolu- 
tions are liable to be flattened, and the pressure may be so great that the 
amount of blood circulating in the brain is reduced below the normal quan- 
tity. Thus, in the case of a child of three years who lived sixteen days, and 
was examined after death by Burdon-Sanderson, the ventricles contained a 
large amount of turbid serum and the brain-substance was everywhere pale 
and anaemic from compression. 

Cerebral ramoIUssement occurs in certain cases. At one of the examina- 
tions in Charity Hospital, the patient having been only three days sick, the 
brain was found much softened. The dissection was made seven hours after 
death, so that the softening could not have been the result of decomposition. 
At one of the post-mortem examinations in Bellevue Hospital softening 
of the fornix, corpus callosum, and septum lucidum was observed, and in 
another softening in: the neighborhood of the subarachnoid space. In a case 
related by Dr. Moorman^ it is stated that portions of the brain, medulla 
oblongata, and pons Varolii were softened. In a case observed by Dr. Upham 
softening of the superior portion of the left cerebral hemisphere had occurred. 
Occasionally the whole brain is somewhat softened. Burdon-Sanderson, Eus- 
sell, and Githens each relate such a case. Moreover, the walls of the lateral 
ventricles are ordinarily more or less softened in fatal cases of cerebro-spinal 
fever, as they are in other forms of meningitis. In rare instances the brain 
is oedematous, as in a case published by Dr. Hutchinson.- In this case the 

^ American Journal of the Medical Sciences. October, 1866. 
'' Ibid., July, 1866. 



494 CEREBROSPINAL FEVER. 

patient was only four days sick and the whole brain was oedematous, serum 
escaping from its incised surface. 

The ventricles contain liquid, in some patients transparent serum, in 
others serum turbid and containing flocculi of fibrin or fibrin with pus. The 
liquids in the different ventricles, since they intercommunicate, are the same. 
The choroid plexus is either injected or it is infiltrated with fibrin and pus. 
With the abatement of the inflammation absorption commences. The serum, 
from its nature, is readily absorbed, and the pus and fibrin more slowly by 
fatty degeneration and liquefaction. Occasionally the serum remains, and 
chronic hydrocephalus results. An infant who contracted the disease at the 
age of five months, and appeared to be convalescent, had, two months sub- 
sequently, great prominence of the anterior fontanel, and other symptoms 
indicating the presence of a considerable amount of effusion within the 
cranium. In another case, one year afterward, examination showed the 
enlargement of the head and prominence of the fontanel which characterize 
chronic hydrocephalus. A boy of ten years treated in Roosevelt Hospital in 
1878 died three months after the commencement of cerebro-spinal fever. 
The records of the autopsy state : " Body a skeleton ; brain, dura mater, and 
pia mater appear normal, except a little thickening of latter at base of brain ; 
ventricles much enlarged and full of clear serum ; surface of walls of ven- 
tricles appears normal, but is soft ; spinal cord and membranes apparently 
normal ; heart, lungs, stomach, and intestines normal ; liver congested ; kid- 
neys pale." In this case, therefore, all the other lesions of the cerebro-spinal 
axis, except the serous effusion, had nearly disappeared. No post-mortem 
examinations, so far as I am aware, have yet revealed the state of the brain 
and its meninges in those who have had this malady at some former time and 
have fully recovered, whether there may not be some traces of it which are 
permanent, as opacity or adhesions. 

The remarks made in reference to the cerebral apply, for the most part, 
also to to the spinal meninges. There is at first intense hyperaemia of the 
membranes, usually over the entire surface of the cord, soon followed by 
fibrinous, purulent, and serous exudation in the meshes of the pia mater and 
underneath this membrane. This exudation is sometimes confined to a por- 
tion of the meninges, more frequently that covering the posterior than the 
anterior aspect of the cord, and when it is general it is ordinarily thicker 
posteriorly than anteriorly. In severe cases nearly or quite the entire spinal 
pia mater may be infiltrated by inflammatory products. Thus, in the case of 
an infant that died of cerebro-spinal fever at the age of ten weeks, in the 
service of Dr. H. D. Chapin, in the Out-door Department at Bellevue, the 
entire spinal cord was covered by a fibrino-purulent exudation, except a space 
about six lines in extent upon the anterior surface. 

No constant or uniform lesions occur in the organs of the trunk, and 
those observed are not distinctive of this disease. Hypostatic congestion 
of the lungs, bronchitis, atelectasis, and broncho-pneumonia are common. 
Pleuritic, endocardial, and pericardial inflammations have occasionally been 
observed, but are rare. Effusion of serum, sometimes blood-stained, occasion- 
ally occurs in the pleural and other serous cavities. The auricles and ven- 
tricles of the heart, as already stated, contain more or less blood, with soft 
dark clots in the more malignant and rapidly fatal cases, but larger and firmer 
in those which have been more protracted. The spleen is enlarged in less 
than half the patients. The absence of uniformity as regards the state of 
the spleen, the fact that in many it undergoes no appreciable change, is 
important, since this organ is so generally enlarged and softened in the infec- 
tious diseases. The stomach, intestines, and liver are sometimes more or less 
congested, but in other cases their appearance is normal. The agminate and 



PROGNOSIS. 495 

solitary glands of the intestines have ordinarily been overlooked, but in cer- 
tain cases they have been found prominent. The kidneys are normal, or they 
exhibit the lesions of nephritis. In 1 of 8 autopsies made by Prof. Welch 
acute diffuse nephritis had been present, as shown by the state of the kidneys. 
In the case of a child of nine years treated by Dr. F. A. Burrall in the 
Presbyterian Hospital the urine was very albuminous and the kidneys pre- 
sented a fatty appearance. Anatomical changes in these organs, however, are 
not common, unless in slight degree, so that in most patients their function is 
fully and properly performed. 

Prognosis. — Cerebro-spinal fever is justly regarded as one of the most 
dangerous maladies of childhood. It is dreaded not only on account of the 
great mortality which attends it, but also on account of its protracted course, 
the suffering which it causes, the possible permanent injury of the important 
organ which is chiefly involved, and the not infrequent irreparable damage 
which the eye and ear sustain. 

I have the records of the result in 52 cases which I attended or saw in 
consultation in the epidemic of 1872. Of these just one-half recovered. 16 
of the 26 who died were hopelessly comatose within the first seven days, 
most of them dying within that time, and some even on the first and second 
days, while others of the ] 6 lingered into the second week and died without 
any sign of returning consciousness. The remaining 10, who subsequently 
died, but did not become comatose in the first week, were nevertheless seri- 
ously sick from the first day, but their symptoms, though severe, were not 
such as necessarily indicated a fatal result, so that there was some expecta- 
tion of a favorable ending till near death, which occurred for the most part 
from asthenia. One succumbed to purpura hsemorrhagica, the hemorrhages 
occurring from the mucous surfaces. The patient died after a sickness of 
more than two months, in a state of extreme emaciation and prostration. The 
26 who recovered convalesced slowly, and usually after many fluctuations. 
Their highest temperature and most severe and dangerous symptoms occurred 
in the first week. Most of them were several weeks under observation and 
treatment before they sufliciently recovered to be out of danger. The statis- 
tics of this epidemic therefore show — and the same is true of other epidemics 
— that the first week is the time of greatest danger, and if no fatal symp- 
toms are developed during this week recovery is probable with proper thera- 
peutic measures and kind, intelligent, and efficient nursing, which is very 
important. 

Since 1872 I have seen a larger number, but have preserved records of 
40 cases which I was able to follow to the close. Some were seen in consul- 
tation. Of these 40, 21 recovered and 19 died. Of the 19 fatal cases, 9 
died in the first week, 5 in the second week. 1 in the third week, 1 on the 
twenty-fifth day, 1 on the thirty-first day, and 1 in the sixteenth week. This 
last patient, a boy of ten years, would, in my opinion, have recovered with 
better nursing. His death occurred from large bed-sores which extended to 
the bones, producedby lying a long time in one position on a hard bed when 
he was too weak to move, and often with soiled bedclothes underneath him. 
The remaining case of the 19 died after a prolonged sickness. 

There is probably no disease which falsifies the predictions of the phy- 
sician more frequently than cerebro-spinal fever. This is due partly to the 
severity of the cerebral symptoms in the commencement, which, did they 
occur in other forms of meningitis with which he is more familiar, would 
justify an unfavorable prognosis, and partly to the remissions and exacerba- 
tions, the occurrence alternately of S3miptoms of apparent convalescence and 
recrudescence or relapse which characterize the course of this malady. Grrave 
initial symptoms, which may appear to have a fatal augury, are often fol- 



496 CEREBROSPINAL FEVER. 

lowed by such a remission that all danger seems past, and in a few hours 
later perhaps the symptoms are nearly or quite as grave as at first. 

Under the age of five years and over that of thirty the prognosis is less 
favorable than between these ages. An abrupt and violent commencement, 
profound stupor, convulsions, active delirium, and great elevation of tempera- 
ture are symptoms which should excite solicitude and render the prognosis 
guarded. If the temperature remain above 105° F., death is probable, even 
with moderate stupor. Numerous and large petechial eruptions show a pro- 
foundly altered state of the blood, and are therefore a bad prognostic ; and so 
is continued albuminuria, since it shows great blood-change or nephritis, while 
other organs than the kidneys are probably also involved. In one case, a boy 
whom I examined nearly a year after the cerebro-spinal fever, the kidneys 
were still afi'ected. He had anasarca of the face and extremities, with albu- 
minuria. Chronic Bright's disease had occurred from the acute nephritis 
which complicated cerebro-spinal fever. Profound stupor, though a danger- 
ous symptom, is not necessarily fatal so long as the patient can be aroused to 
partial consciousness and the pupils are responsive to light ; so long as it 
does not pass into actual coma it is less dangerous than active or maniacal 
delirium, which is likely to eventuate in this coma. 

A mild commencement with general mildness of symptoms, as the ability 
to comprehend and answer questions, moderate pain and muscular rigidity, 
some appetite, moderate emaciation, little vomiting, etc., justify a favorable 
prognosis, but even in such cases it should be guarded till convalescence is 
fully established. 

We may repeat and emphasize the important fact shown by the above 
statistics that patients who live till the close of the second week without 
serious complications will probably recover. The danger after this period 
is, in most instances, from exhaustion and feeble action of the heart, result- 
ing from the impaired nutrition and the protracted course of the disease. 

Complications which most frequently pertain to the lungs increase greatly 
the gravity of many cases and contribute to the fatal ending. The fact that 
Webber in his prize essay describes a variety of cerebro-spinal fever which he 
designates pneumonic, and that those who make post-mortem examinations 
find that '•' oedema, hypostatic congestion of the lungs, bronchitis, atelectasis, 
and broncho-pneumonia are extremely common lesions in cerebro-spinal men- 
ingitis " (Welch), indicate a source of danger in addition to that located in 
the cerebro-spinal system. One close observer of an epidemic writes : " In 
all the fatal cases which came under my notice the most prominent symptoms 
which preceded death were those which indicate impairment and perversion 
of the respiratory functions. As the breathing became more hurried and 
difficult the general depression became more intense, the pulse became weaker 
and quicker, and the temperature of the skin more elevated." 

Parenchymatous degeneration of the liver and kidneys is another serious 
complication. The kidneys are probably more frequently, and to a greater 
extent, diseased than the liver. We have already stated that nephritis was 
present in 1 of the 8 cases examined by Prof. Welch. In the Revue medi- 
cale for June 3, 1882, M. Ernest Gaudier published the case of a female 
who died comatose on the sixth day of cerebro-spinal fever. Examination 
of the urine had revealed the presence of " retractile albumen of Prof. 
Bouchard, attributable to renal lesions, and non-retractile albumen, consid- 
ered as an indication of some general infection of the system." Microscopic 
examination of the kidneys " showed considerable swelling and granular 
degeneration of the renal epithelial cells, with effusion of granular matter 
within the lumina of the tubules." We have seen from the case referred to 
above that the renal complication may persist and become chronic. Those 



DIAGNOSIS— TREATMENT. 497 

who fully recover often exhibit symptoms usually of a nervous character, 
as irritability of disposition, headache, etc., for months or years after con- 
valescence is established. 

Diagnosis. — Cerebro-spinal fever, on account of the nature and severity 
of its symptoms and the suddenness of its onset, may be mistaken for scarlet 
fever, and vice versa. In one instance, to my knowledge, this mistake was 
made. High febrile movement, vomiting, convulsions, and stupor are com- 
mon in the commencement of scarlet fever, and the same symptoms commonly 
usher in the severer forms of cerebro-spinal fever. It will aid in diagnosis to 
ascertain whether there be redness of the fauces, for this is present in the 
commencement of scarlet fever, and a few hours later the characteristic efflo- 
rescence appears on the skin. 

The diagnosis of cerebro-spinal fever from the common forms of menin- 
gitis is ordinarily not difficult, for while in the former the maximum inten- 
sity of symptoms occurs in the first days, in the latter there is gradual and 
progressive increase of symptoms from a comparatively mild commencement. 
Moreover, cases of ordinary or sporadic meningitis occurring at the age 
when cerebro-spinal fever is most frequent are commonly secondary, being 
due to tubercles, caries of the petrous portion of the temporal bone, or other 
lesion, and are therefore preceded and accompanied by symptoms which are 
directly referable to the primary disease. We have seen how different it is 
in cerebro-spinal fever, which in most patients begins abruptly in a state of 
previous good health. Again, in cerebro-spinal fever after the second or 
third day hyperaesthesia, retraction of the head, and other characteristic 
symptoms occur, which are either not present or are much less pronounced 
in ordinary meningitis. Some of the milder cases of cerebro-spinal fever 
might be mistaken for hysteria, but the pain in the head and elsewhere, the 
muscular rigidity, and especially the occurrence of more or less fever, 
enable us to make the diagnosis. Continued fever, typhus or typhoid, 
resembles cerebro-spinal fever in certain particulars, but it lacks the muscu- 
lar contraction and rigidity which characterize the latter. It does not usu- 
ally begin so abruptly, with such severe symptoms, especially such severe 
headache, has less marked fluctuations, and a more definite duration. These 
facts in connection with the character of the prevailing epidemic will enable 
us to make the diagnosis. In one instance commencing retro-pharyngeal 
abscess, probably associated with vertebral caries, was at first mistaken by 
me for cerebro-spinal fever. The patient was an infant, had a temperature 
of 104° F., stiff"ness of the neck with some retraction of the head, and cried 
from pain when the head was brought forward. The speedy occurrence of 
two large abscesses in other parts of the system, difficult deglutition, and 
noisy respiration, led to a digital exploration of the fauces, when the abscess 
was found and opened. 

Treatment. — Since in epidemics of cerebro-spinal fever cases are more 
frequent and severe where antihygienic conditions exist, it is evident that 
measures looking to the removal of such conditions, measures designed to 
procure pure air in the domicile, wholesome diet, and a quiet and regular 
mode of life — in fine, measures designed to produce the highest degree of 
health — are of the first importance for the prevention of the disease. 
Cleanliness of the streets and areas, as well as of the apartments, good 
sewerage and drainage, the prompt removal of all refuse matter, avoidance 
of overcrowding — in a word, the strict observance of sanitary requirements 
in every particular — will, there can be little doubt from what we know of 
the causation and nature of cerebro-spinal fever, diminish the number and 
severity of the cases. The avoidance of fatigue and overwork and of men- 
tal excitement, the use of plain and wholesome diet, sufficient sleep, the 
32 



498 CEREBROSPINAL FEVER. 

utmost regularity in the mode of life, with the least possible exposure to 
depressing agencies, are the important preventive measures which should be 
recommended during an epidemic of cerebro-spinal fever. 

The enjoining of a quiet and regular mode of life as a preventive 
measure during the occurrence of an epidemic of cerebro-spinal fever is 
not inconsistent with the theory that the cause is a micro-organism. It is 
not unreasonable to suppose that the system may be more or less under tha 
influence of the specific principle, and that this principle may obtain lodg- 
ment in the blood or tissues without result until some exciting cause occurs 
which depresses the system and disturbs the functions, when the resisting 
power fails and cerebro-spinal fever appears; just as those exposed to 
Asiatic cholera may remain well until some imprudence in the diet or the 
mode of life causes an outbreak of the malady. 

Curative Treatment. — In the commencement of cerebro-spinal fever 
intense inflammatory congestion occurs of the cerebral and spinal meninges, 
and also to a certain extent of the brain and spinal cord. As regards treat- 
ment, the obvious indication is to reduce the hyperaemia of the vessels as 
quickly as possible and subdue or diminish the inflammation. For this pur- 
pose bags or bladders of ice should be immediately applied over the head 
and to the nucha, and constantly retained there as long as there is no com- 
plaint of chilliness, no marked diminution of temperature, and the patient 
experiences some relief from the intense headache and other symptoms. 
Bran mixed with pounded ice produces a more uniform coldness and is some- 
times more agreeable to the patient than the ice alone. The bag or bags 
should be about one-third full, so as to fit upon the head like a cap, and the 
nurse should be instructed to renew the ice as soon as it melts. In severe 
cases with marked elevation of temperature it is proper to apply cold over 
the dorsal and lumbar vertebrae, as well as upon the head and nucha. A 
hot mustard foot-bath or a general warm bath in those cases in which con- 
vulsions are present or threatening, or in which there is delirium or great 
agitation or severe peripheral pains, is also useful, since it has a calmative 
effect and acts as a derivative from the hyperaemic nerve-centres. One 
writer states that he obtained marked benefit in a case by immersing the 
body to the neck in hot water. 

The abstraction of blood, usually by leeches applied to the temples, 
behind the ears, or along the spine, has been employed, but even in the com- 
mencement of the present century, when it was customary to bleed generally 
and locally in the treatment of inflammatory and febrile diseases, a majority 
of the American physicians whose writings are extant discountenanced the 
abstraction of blood in the treatment of this disease. Drs. Strong, Foot, 
and Miner, though under the influence of the Broussaisian doctrine, were good 
observers, and they soon abandoned the use of the lancet and leeches in the 
treatment of these patients for more sustaining measures. Strong^ states that 
certain physicians employed venesection as a means of relieving the internal 
congestions, but, finding that the pulse became more frequent after a mode- 
rate loss of blood, they soon laid aside the lancet. Some experienced physi- 
cians of that period, however, continued to recommend and practise deple- 
tion, general as well as local, as, for example. Dr. Gallop, who treated many 
cases in Vermont in the epidemic of 1811. 

Venesection in the treatment of cerebro-spinal fever is universally dis- 
carded at the present time in this country and Europe, but some intelligent 
physicians, as Sanderson and Niemeyer, approve of local bleeding in certain 
cases. It is, in my opinion, after examining the histories of many cases, uncer- 
tain whether the abstraction of blood should ever be recommended, but if it 
^ Medical and Physiological Register, 1811. 



TREATMENT. 499 

be prescribed it should be on the first day, when the hyperemia is greatest, 
by the application of only a few leeches behind the ears, and never except 
when coma or convulsions are present or threatening and the patient is robust. 
The fact should not be forgotten that cerebro-spinal fever is in its nature 
asthenic and protracted, and that the intense inflammatory congestion of the 
nervous centres can ordinarily be relieved, if relieved at all, by the other 
measures recommended, which do not reduce the strength. The alarming 
symptoms which usher in an attack, the intense headache, restlessness, deli- 
rium, sometimes eclampsia or coma, seem to demand the most energetic treat- 
ment, and yet it is surprising to one who has his first experiences with this 
malady how patients under proper treatment, without the abstraction of 
blood, emerge from an apparently almost hopeless state and ultimately recover. 
There may be total unconsciousness, the pupils dilated like rings and insen- 
sible to light, the head intensely hot, tonic convulsions present or alternating 
with frequent clonic convulsions, and yet these symptoms, which in any other 
disease would be regarded as sufiicient to justify the prognosis of certain 
death, may gradually pass off toward the close of the first or in the second 
week, and the case afterward progress favorably. In the New York epidemic 
of 1872 — previous to which physicians of this city had no personal experience 
with cerebro-spinal fever — many cases were pronounced hopeless which ulti- 
mately did well without abstraction of blood. In a case occurring in the 
practice of Dr. Griswold the patient was comatose for three days, with pupils 
not responding or but very feebly responding to light, but he recovered with- 
out the abstraction of blood and with the remedies ordinarily employed. In 
a case which we will presently relate in speaking of another local treatment 
the patient was still insensible in the third week, with pupils greatly dilated 
and insensible to light, and yet recovered without losing blood. Such cases 
show that the most urgent symptoms, such as seem to indicate the prompt 
employment of leeches in order to reduce the meningeal hyperagmia and the 
consecutive congestion of the nerve-centres, may be relieved and the patient 
recover without such depletion, and with the preservation of the blood, which 
is so much needed in the subsequent asthenic course of the malady. 

In only one case have I recommended the abstraction of blood, and this 
was so instructive that I will briefly relate it : A girl four years of age was 
seized on March 7, 1873, with vomiting, chilliness, and trembling, followed 
by severe general clonic convulsions lasting about fifteen minutes; was semi- 
comatose ; pulse 132, and a few hours later 156 ; temperature 101 i° F. ; res- 
piration 44 ; eyes closed, pupils moderately dilated and feebly responsive to 
light, dusky mottling of skin, constant tremulousness with twitching of limbs. 
Bromide of potassium was administered in hourly doses of four grains, ice 
applied to the head and nucha, and a hot mustard foot-bath followed by sina- 
pisms to the nucha. On the following day, March 8th, she was partly conscious 
when aroused, but immediately relapsed into sleep ; head retracted, bowels 
constipated ; pulse 136 ; temperature 102° ; vomited occasionally. It was 
thought proper, on account of the extreme stupor, to apply one leech to 
each temple, and the bites trickled slowly nearly five hours. The other 
treatment was continued. On the 9th the-pulse was 180 — so feeble that it 
was counted with difficulty ; temperature 1015°. The patient was evidently 
sinking. It was necessary to order whiskey in teaspoonful doses every two 
hours, with beef tea and other most nutritious drinks. Evening, pulse 172, 
still feeble. March 10th, pulse 180, barely perceptible ; great hypergesthesia ; 
axillary temperature 100° ; axes of eyes directed downward. After this the 
patient gradually rallied for a time, the pulse becoming stronger and less 
frequent, but death finally occurred after nine weeks in a state of extreme 
emaciation and exhaustion. Slight convulsions occurred in the last hours. 



500 CEREBROSPINAL FEVER. 

It is seen that in the above case, which may be regarded as typical, the 
patient passed into a state of extreme prostration after the application of the 
leeches, so that for three days I did not believe that she would live from hour to 
hour, and death occurred after an illness of nine weeks, apparently from sheer 
exhaustion. Experience like this, which corresponds with that of most other 
observers, shows the necessity of preserving , the blood, and thereby the 
strength, however urgent the initial symptoms, inasmuch as cerebro-spinal 
fever in its subsequent course is attended by such marked asthenia. On 
May 3, 1878, a boy of ten years was admitted into one of the New York 
hospitals in the service of a prominent physician. It was stated that he 
had been four days sick with cerebro-spinal fever, and among other charac- 
teristic symptoms he had had delirium every night, and on May 2d delirium 
in the day-time, which had abated considerably after free epistaxis. In the 
hospital the application of ten leeches along the spine was ordered, but it 
does not appear to have diminished the delirium or any other symptom, and 
the following day the pulse was so frequent and feeble that active stimula- 
tion by brandy was resorted to. He had three strong convulsions on May 
13th, which were relieved b}^ ice to the head and nape of neck and by six 
minims of Magendie's solution. Severe pains occurred at times in the back 
and limbs, and on the 29th, one month after the commencement of the dis- 
ease, the same pain frequently recurring, twelve leeches were ordered to be 
applied to the spine. On June 2d the limbs were flexed and quite stiff, and 
the effort to move them was attended by great pain. The pain in the back 
was also more constant, and in consequence sixteen leeches were applied to 
the spine The next day there was no pain, but the patient was very stupid. 
On June 6th the records state that he was obviously losing strength day by 
day — that his emaciation was extreme and his anaemia very marked. But 
he had great vitality, and, although he had strabismus, bed-sores, incontinence 
of urine and feces, and extreme prostration, he lingered till August 1st. At 
the autopsy : " Body a skeleton ; brain, dura mater, and pia mater appear 
normal, except a little thickening of latter at base of brain ; ventricles much 
enlarged and full of clear serum ; surface of walls of ventricles looks normal, 
but is soft; spinal cord and membranes appear normal to the naked eye." 
No disease was discovered in other organs, except that the liver appeared con- 
gested and the kidneys pale. It can scarcely be doubted that although some 
temporary relief from the pain may have resulted to this patient by the 
repeated application of leeches, which diminished the meningeal hyperaemia, 
yet his chances for ultimate recovery would have been far better without such 
depletion. Therefore the histories of cases show that the result of abstrac- 
tion of blood has been unsatisfactory, on account of the asthenic nature and 
protracted course of cerebro-spinal fever, and it should never be recommended 
as a remedial agent. 

Some benefit is apparently derived from the application of stimulating 
and moderately irritating lotions along the spine. A liniment consisting of 
equal parts of camphorated oil and turpentine briskly applied by friction 
with flannel up and down the spine till redness is produced appears to cause 
some alleviation of the suffering, and it does not conflict with the use of the 
ice-bag. Dr. William H. Sutton of Dallas, Texas, has published the follow- 
ing interesting case, showing the benefit from stimulating and irritant appli- 
cations over the spine made in an unusual manner : A child aged three and a 
half years had been three weeks under treatment, through error of diagnosis, 
for supposed continued fever. When Dr. Sutton assumed charge of the 
case, November 20, 1877, the pupils were greatly dilated and insensible to 
light; features pallid and pinched ; pulse 130 ; temperature 103° F. ; patient 
totally unconscious. November 21st, morning temperature 105°, pulse 140; 



TREATMENT. 501 

evening temperature 101 i^°, pulse 120. November 22d, morning temperature 
106i°, pulse 160; restless; evening temperature 105^]°, pulse 120; had not 
slept, except for moments, for nearly two weeks. A strip of flannel saturated 
with turpentine was placed over the spine from the neck to the sacrum, and 
a hot smoothing-iron was run up and down it, and eight drops of the fluid 
extract of ergot were given every three hours. Dr. Sutton adds : " The 
father stated to me that as soon as the application was finished the child fell 
asleep, and slept several hours — the first for two weeks — and the fever rapidly 
declined. From this time he began to improve, and gradually and fully recov- 
ered." The use of irritants and derivatives over the spine in the treatment 
of cerebro-spinal fever has been long and favorably known, but the mode 
of producing irritation in the above case was novel. 

Internal Treatment. — It will aid in the selection of the proper remedies to 
recall to mind the pathological state which we know to be present from the 
many autopsies which have been recorded. We have seen that the largest 
mortality, and consequently the most dangerous period, is in the first days, 
when there is intense, suddenly-developed inflammatory congestion of the 
meninges, with more or less secondary hypersemia of the underlying brain 
and spinal cord, producing great headache, delirium, or somnolence, with 
exaggerated reflex irritability of the spinal cord, so that eclampsia is a com- 
mon and fatal complication. 

Fortunately, a remedy has been discovered in modern times (the bromide 
of potassium) which acts promptly and efiiciently. It can be safely admin- 
istered in large and frequent doses to the youngest child. It is quickly elim- 
inated from the system through the kidneys and other emunctories in chil- 
dren, so as to prevent the occurrence of bromism, at least to the extent of 
causing any unpleasant consequences. It causes contraction of the minute 
vessels of the nervous centres so as to diminish the hypersemia, as shown by 
the experiments and observations of Dr. Putnam-Jacobi and others, and at 
the same time it diminishes, in a marked degree, the reflex irritability of the 
spinal cord — two most beneficial and important eff"ects of its use in this dis- 
ease. Many children by its timely employment are saved from the dangers 
of eclampsia, and by its sedative efl"ect on the nervous system and contractile 
action on the capillaries it probably diminishes the intensity of the inflam- 
mation and the amount of exudation. I usually prescribe it, as recommended 
by Dr. Squibb, dissolved in simple cold water. In ordinary cases, not attended 
by eclampsia or marked symptoms which show that eclampsia is threatening, 
I generally prescribe at my first visit about four grains every two hours to a 
child of two years who has the usual restlessness and apparent headache, 
and six grains to a child of five years. If eclampsia occur, the bromide 
should be given more frequently, as every five or ten minutes, till it ceases. 
It is important to be able to determine when the quantity of the bromide 
administered should be diminished and when its use should be discontinued. 
I have very rarely observed bromism in children, and never to the extent of 
doing any serious harm, though for many years I have administered it in 
large and frequent doses whenever the occasion seemed to require it; but 
the symptoms of bromism cannot readily be discriminated from those which 
may result from cerebro-spinal fever, such as muscular weakness, dilated 
pupils, with perhaps impaired vision, unsteady gait, nausea or vomiting, and 
abdominal pains. If the case progress favorably, frequent and large doses 
should, in my opinion, be given only in the first week, after which this agent 
should be given at longer intervals or in smaller doses. But during exacer- 
bations, which are liable to occur from time to time till the patient is well on 
the way to recovery, the use of the bromide in full doses is again indicated 
till the urgent symptoms begin to abate. 



502 CEREBROSPINAL FEVER. 

Phenacetin promises also to be another useful remedy in this disease, from 
its well-known action in relieving headache, reducing fever, and procuring 
sleep. It may be administered with the bromide. It appears to be a very 
useful adjuvant to the bromide during the first week, when the temperature 
is most elevated and the headache severe. At a later stage, when asthenic 
symptoms are more pronounced, its use appears to be contraindicated, unless 
in exceptional instances. Antipyrine has been used in place of phenacetin, 
but it appears to be more depressing. 

Ergot is another very important remedy. It is scarcely less useful than 
the bromide, from its action in contracting the arterioles and diminishing the 
flow of arterial blood. The fluid extract, tincture, or wine of secale cornutum 
can be employed or its active principle, ergotin. Squibb's fluid extract has 
been more used in New York City than any other preparation. I have com- 
monly prescribed it, except for patients old enough to take ergotin in the pill. 
The doses employed by diff"erent physicians vary greatly. Dr. William A. 
Thomson, professor of Materia Medica in the New York University, has pre- 
scribed, so far as I am aware, the largest doses in the treatment of this dis- 
ease — to wit, one teaspoonful of the fluid extract of secale cornutum every 
three hours to a boy of ten years, in Roosevelt Hospital in 1878, with apparent 
benefit as regards the meningeal hypersemia, although the case was fatal after 
the lapse of several months from asthenia. The alkaloid ergotin, to which 
the beneficial effects of the secale cornutum are due, may be given in the pill 
or in solution. In case of much irritability of the stomach it can be employed 
hypodermically, dissolved in water with glycerin. The efficacy of this agent 
is most marked during the first and second weeks, when the congestion of 
the nervous centres is greatest. At a more advanced stage, when there is 
less congestion and the danger arises from the inflammatory products and 
structural changes, the time for the use of ergot is past, or if it is still of 
some service it is less needed than at first and should be given less frequently. 

The severe headache and restlessness which attend many cases require 
the occasional use of an opiate or the hydrate of chloral. Chloral in proper 
dose never fails to give quiet sleep, and it is supposed by some who have 
studied its therapeutic action that it diminishes the cerebral circulation. It 
is therefore a useful adjuvant to the bromide. Five grains usually sufiice 
for a child of six to eight years. Chloral is especially useful in cases 
attended by eclampsia or by symptoms which threaten eclampsia, since it acts 
promptly and decidedly in diminishing reflex irritability. Formerly it was 
considered injudicious and unsafe to prescribe opiates in meningeal inflamma- 
tion, since it was supposed that they increased the liability to coma, but 
experience shows that they are sometimes very useful in this disease when 
administered in small or moderate doses, and without the risk which was once 
supposed to be incurred by their use. The thirty-second part of a grain of 
morphia administered at intervals of some hours was sufficient to relieve the 
suff"ering of one of my patients at the age of six years. 

Quinia apparently does not exert any marked controlling efi"ect on the 
course of cerebro-spinal fever or its symptoms, although the paroxysmal char 
racter of the severe pains in many patients suggests the use of this agent as 
an antiperiodic. It was frequently prescribed by New York physicians in 
the epidemic of 1872, but I believe that the opinion was unanimous that it 
was not the proper remedy. I have prescribed it in large and small doses, in 
one instance giving fifteen grains to a child of thirteen years, but do not know 
that I have derived any benefit from its use in this malady. It may increase 
the hyperaemia of the meninges and the cerebro-spinal axis. 

When the acute stage has abated measures designed to remove the serum 
which sometimes remains, constituting a hydrocephalus, are indicated. For 



ACUTE RHEUMATISM. 503 

this purpose the iodide of potassium is probably more useful than any other 
agent. It is administered by some physicians early along with the bromide, 
in the same manner in which they have been in the habit of treating other 
forms of meningitis. I have prescribed it with the bromide and alone when 
the bromide was discontinued, but whether it produces any marked sorbefa- 
cient effect in this disease apart from the removal of serum seems to me 
doubtful. 

The result depends to a great extent on the nursing. The skill of the 
physician may be thwarted and the life of the patient lost by inefficient 
nursing. Xo other disease more urgently requires kind, intelligent, and con- 
stant attendance night and day on the part of the nurse. Not only should 
the medicines and nutriment be given punctually and regularly, but the 
great restlessness of the patient in the first days requires constant readjusting 
of the ice-bags, and during the long period of convalescence the utmost care 
is required to remove at once the excretions in order to prevent bed-sores, 
and to give the proper amount and kind of nutriment to prevent the emacia- 
tion and weakness from which many perish. 

The diet, from the beginning to the end of the malady, should be the 
most nutritious and such as is easily digested. It is necessary to give it in 
the liquid form, unless in mild cases in which the appetite may not be entirely 
lost. It is proper to aid the digestion by pepsin preparations. Nutritive 
enemata, consisting of beef tea or one of the extracts of beef, milk, and 
brandy, aid in averting the fatal prostration in protracted cases. After the 
acute stage has passed and the meningeal hyperasmia has abated the alcoholic 
compounds in moderate doses, which in the beginning might be injurious, 
may now be useful, administered regularly by the mouth. The room should 
be dark, well ventilated, and quiet. All sympathizing friends who are not 
required in the nursing should be excluded. I know of no other disease in 
which this is so necessary, for mental excitement may produce dangerous 
aggravation of symptoms. 



CHAPTER Y. 

ACUTE KHEUMATISM. 

Rheumatism is a constitutional disease with a local manifestation — to 
wit, inflammation of the fibrous tissues, chiefly in and around the articula- 
tions, but occasionally in other parts, as the heart and nervous centres. It 
was formerly supposed to be rare in children, but more accurate observations 
show that it is scarcely less common during childhood than in adult life. In 
young patients, especially under the age of six or eight years, it is frequently 
overlooked, for the articular inflammations in such patients are commonly 
slight. In the last twenty years, during my connection with the children's 
class in the Bureau for the Relief of the Out-door Poor, I have examined 
many children with rheumatism or the cardiac lesions resulting from rheu- 
matism, and ordinarily I have found that few joints had been affected, and that 
there had been but little swelling of them or redness, and that the patients 
were usually not confined to bed, or even to the sitting posture, but had been 
able to walk about, though with restraint and complaint of pain or soreness. 
The parents in many instances supposed that their children were suffering 
from •' growing pains,"' as they designated them. At the same time, with 
this mildness of symptoms the heart was becoming seriously and permanently 



504 ACUTE RHEUMATISM. 

crippled by endocarditis. Those who have attended my clinics will recollect 
that on some days as many as three or four children with cardiac lesions have 
been present whose histories show an overlooked rheumatism of this mild type. 
Oases like the following are very common among the city poor : 

In January, 1871, a little girl three years old was presented, having distinct 
aortic direct and mitral regurgitant murmurs. The mother was not aware that 
she had had rheumatism, but at the age of twenty months she had for several 
days pretty active febrile symptoms, which the physician attributed to some 
other ailment. In April, 1871, another girl, of the same age, was brought to 
the clinic, having a distinct mitral regurgitant murmur. The mother stated 
that she had been well till a month previously, when she was confined to her 
bed for a few days, having a high fever. She was attended by a homoeopathic 
physician, and the exact character of her sickness the mother was not able to 
state. Further medical advice was sought, as the child remained delicate, 
though her health was better than at first. There can be little doubt that 
the obscure fever in this case was rheumatic. In another child treated else- 
where, not old enough to relate the subjective symptoms, there was, in addi- 
tion to an intense fever, evident pain in one foot or leg when the limb was 
moved. Still, the nature of the disease was not diagnosticated till some time 
after recovery, when a valvular murmur was accidentally discovered. Such 
histories, which are not rare, show that rheumatism often occurs in young 
children, even infants, and they inculcate the important practical lesson that 
the disease at this age may be so obscure or latent as to be overlooked even 
by good diagnosticians. 

Some observers, meeting cases of valvular disease in children without the 
history of rheumatism, have concluded that rheumatism is not the chief cause 
of endocarditis at this age;^ but the explanation which I have given seems 
to me more in consonance with the facts. Scarlet fever not infrequently 
causes endocarditis, but this exanthem seldom occurs without detection, and 
it has been as often absent as has rheumatism from the histories as given by 
the parents of young children with valvular disease whom I have examined. 
Moreover, the endocarditis of scarlet fever is in many cases associated with, 
if it do not result from, scarlatinous rheumatism. 

Rheumatism in children is primary or secondary. The secondary form 
occurs chiefly in the declining stage of scarlet fever and variola. It is stated 
also to occur occasionally in new-born infants during epidemics of puerperal 
fever, but I have not observed such cases. 

Causes. — An inherited rheumatic diathesis is universally recognized as 
an important predisposing cause of this disease, so that it frequently occurs 
in different members of the same family. When the family history shows a 
strong predisposition to rheumatism, it occurs in the child from a slight 
exciting cause ; if no such predisposition exist, it only occurs through 
unusual circumstances of exposure. Investigations have been made in order 
to determine whether acute rheumatism is a microbic disease. Dr. Alfred 
Mantle of England made cultures from the serum of 7 and from the blood 
of 16 patients with acute rheumatism. He states that he made use of every 
precaution to prevent contamination by germs from without. The organisms 
obtained by Mantle in the cultures were a micrococcus and a small bacillus. 
He states that these organisms produced lactic-acid fermentation in sterilized 
milk. He believes that the microbes do not produce the symptoms of rheu- 
matism by their direct action, but by the ptomaines to which they give rise, 
and he raises the question whether lactic acid is not the chief ptomaine 
(Brit. Med. Jour., 1887). Popow states that the micrococci obtained by cul- 
tivation from the blood of rheumatic patients inoculated in rabbits caused 

1 Dr. A. StefFen, Jahrbuch far Kinderk, 1870. 



SYMPT03IS. 505 

in these animals the characteristic symptoms of rheumatism, and in their 
blood and synovial fluid he found the same cocci (^Wiener nied. Presse^ Jan. 
29, 1888). Cornil and Babes have also related a fatal case of rheumatism in 
which micrococci and bacilli were found in the right knee. Wilson found 
bacilli in the pericardium in two cases of rheumatic pericarditis. Petrone 
examined the serum taken from the knee-joint in three cases of acute rheu- 
matism, and in all the specimens examined discovered microbes similar to those 
detected by Klebs in rheumatic endocarditis. Jaccoud relates the histories 
of two newly-born infants whose mothers at the time of their birth had acute 
rheumatism. One of them twelve hours after birth, and the other three days 
after birth, " were attacked with fever, rapid pulse, and well-marked rheu- 
matic swelling of several articulations." Under treatment one recovered in 
eight days and the other in a little more than two weeks. The above observa- 
tions lend support to the theory that acute rheumatism is a microbic disease, 
and perhaps observations indicate that it is to a certain extent infectious. 

Children who have had one attack are especially liable to another, and 
when the diathesis is acquired slight exposures appear to be sufficient to cause 
the disease. It has heretofore been the common belief in the profession — 
and this opinion is also held by the laity — that exposure to cold is the usual 
exciting cause of rheumatism ; but if the disease have a microbic origin, it is 
a question whether or to what extent this theory is true. It is stated in sup- 
port of it that rheumatism is most common in cold and changeable weather 
and in those who are most exposed to vicissitudes of temperature. 

Scarlatinous rheumatism has been alluded to above. Frequently during 
the course of scarlet fever inflammation of certain joints occurs which can- 
not be distinguished from that in the ordinary form of rheumatism, and in 
some of these instances endocarditis or pericarditis also occurs. Dr. Ashby 
is inclined to believe that scarlatinous rheumatism is produced by septic 
poisoning, but it sometimes occurs at such an early stage or in cases of such 
mildness that the conditions giving rise to ordinary sepsis do not seem to be 
present. It is therefore probable, in my opinion, that in some instances at 
least this articular affection occurring in scarlet fever is due to the direct 
action of the scarlatinous microbe or to a ptomaine or ptomaines produced 
by this microbe. 

Symptoms. — The commencement of acute idiopathic rheumatism is in 
most cases sudden ; occasionally fever and a degree of soreness or stifi'ness 
precede the articular affection for a few hours or days. The inflammation, 
slight at first, increases gradually, attaining its maximum intensity within one 
or two days. The joint is painful, red, hot, and swollen. The swelling is 
due to inflammatory oedema of the tissues surrounding the joint and eff'usion 
within the joint. As in all inflammations, the vascularity of the parts 
involved is increased, the synovial membrane loses, more or less, its lustre, 
and the eff"used fluid, which is mainly serum, has been found, in most of the 
cases in which an opportunity was presented of examining it, to contain a few 
leucocytes. Rarely fibrin is exuded, producing a rubbing sensation when 
the joint is moved, and perhaps impairing the mobility of the articular 
surfaces. Fortunately, however, in a large majority of cases the substance 
exuded both without and within the joint is mainly serum, and hence the 
rapid subsidence of the swelling when the inflammation ceases. The pain is 
commonly not severe when the child is quiet, but it is greatly increased if the 
joint be pressed or the limb moved. 

The joints of the extremities are most frequently the seat of rheumatic 
inflammation, but occasionally those of the trunk, as the intervertebral, the 
symphysis pubis, etc., are involved. As the inflammation abates in the artic- 
ulations first affected it reappears in others, unless the materies morbi have 



506 ACUTE RHEUMATISM. 

been eliminated from the system. It is seldom that more than two or three 
of the joints are in a state of active inflammation at the same time. 

The temperature in acute rheumatism is elevated two or three degrees 
above that of health, and the pulse varies from 120 to 140, its frequency- 
depending on the age of the patient as well as the gravity of the disease. 
Perspiration is a common symptom. The appetite is impaired, the tongue 
slightly coated, and the bowels constipated. The watery element of the 
urine is diminished, as in most febrile diseases, and there is not a correspond- 
ing reduction in the solid elements, so that the urine is rendered more dense 
and its specific gravity is high. The amount of urea and coloring matter 
excreted from the kidneys is augmented during the active period of rheuma- 
tism, and the urine when it cools deposits urates. In ordinary cases there is 
no prominent symptom referable to the nervous system, with the exception 
of pain in the affected joint. 

Acute rheumatism, if only the articulations were involved, would be a dis- 
ease of little danger, however painful, but unfortunately in its proneness to 
produce specific inflammation of the sero-fibrous tissues the heart frequently 
becomes involved, less frequently the lungs and pleura, and in rare instances 
the cerebral or spinal meninges. The so-called cerebral rheumatism is attended 
by high fever, restlessness, headache, and sometimes delirium and coma. 
Twitching of the muscles and sometimes tonic or clonic spasms occur. Prof. 
Flint says: "In the majority of cases death takes place during coma. In 
some cases recovery sets in even after the appearance of very grave symp- 
toms. In fatal cases no lesions of the brain or of the meninges can really 
be found. The symptoms seem to be referable to some profound infection or 
intoxication which acts upon the thermic and other nervous centres." This 
form of rheumatism is certainly rare in childhood. Endocarditis is the most 
frequent of the heart inflammations occurring in rheumatism ; pericarditis, 
though less common, is not infrequent ; while in rare instances myocarditis 
occurs, usually associated with the other inflammations. Endocarditis is 
limited to the left side of the heart, and seldom continues long without 
engaging the valves, aortic or mitral, or both, causing their infiltration, 
fibroid degeneration, with consequent thickening, and sometimes adhesion. 
The valvular lesion thus produced is in most instances permanent, so impair- 
ing the action of the valves as to obstruct in greater or less degree the flow 
of blood through the orifice and allow its regurgitation. 

The mitral valve is more frequently aff"ected than the aortic ; at least bruits 
produced by this lesion are more frequent in the mitral than aortic orifice, and 
when they are heard in both orifices they are commonly loudest in the mitral. 
This fact, noticed by difi"erent observers, I have repeatedly verified by obser- 
vations in this city. 

I have preserved the records of 73 cases of valvular disease in children, 
and in most of them I was able to assign rheumatism as the cause, but it 
was in a large proportion of instances very slight, so as not to confine the 
patients to bed, and had been considered by the parents simply " growing 
pains," so that no treatment had been received. The statistics of diff'erent 
observers show that endocarditis in acute rheumatism occurs more frequently 
in children than in adults. The first sign of an endocardial inflammation is 
in most instances a systolic murmur produced in the mitral orifice. It can- be 
heard on listening over the heart, and also over the left scapula. It indicates 
insufficiency of the mitral orifice and regurgitation of blood into the left 
auricle. In some cases the aortic valves are at the same time aff"ected, and 
an aortic direct murmur occurs, synchronous with the mitral regurgitant. 
In rare instances the endocarditis extends to the aortic orifice, causing thick- 
ening of its valves and impairing their action, so that an aortic bruit results, 



PATHOLOGY. 507 

while the mitral orifice is not afi"ected, and therefore no mitral murmur 
occurs. 

Another cardiac bruit resulting from the endocarditis occasionally observed 
is a reduplication of the second sound, heard most distinctly at the apex. A 
diastolic sound sometimes follows this reduplication, and when it is well devel- 
oped it constitutes the so-called presystolic murmur. It usually results from 
mitral stenosis caused by the endocarditis. 

Pericarditis is not so common in rheumatism as endocarditis, but it some- 
times occurs in children as well as in adults. It occasionally even precedes the 
afi'ection of the joints, being the first in time of the rheumatic inflammations. 
It causes an increase in the fever, palpitation, quick and irregular pulse, rest- 
lessness, cardiac pain, and perhaps dyspnoea. At first a pericardial friction- 
sound may be detected, and subsequently, when sero-fibrinous exudation has 
occurred, the area of dulness may be increased, with a muffling of the sounds 
of the heart. If the effusion of serum be moderate, the pericardial sur- 
faces may become agglutinated early in the disease, or they may become 
agglutinated after the serum is absorbed, so as to prevent friction-sound. An 
adherent pericardium embarrasses the action of the heart, and is likely to lead 
eventually to hypertrophy. Tonsillitis occurs so frequently in children who 
have the rheumatic diathesis, and also so frequently during rheumatism, that 
Trousseau recognized a rheumatic form of the disease. Bronchitis, pleurisy, 
and pneumonia also occasionally occur as complications of rheumatism. 

While the articular aff"ections pertain to the clinical history of rheumatism, 
the internal inflammation, whether of the heart, lungs, pleura, or meninges, 
though similar as regards its pathological character, is properly considered as 
a complication. Acute rheumatism is so frequently complicated by one or 
the other of these aff'ections that any disproportionate severity in the general 
symptoms, as compared with the inflammation of the joints, or any sudden 
and unexpected increase in the symptoms, should always lead the physician 
to examine thoroughly the condition of those organs which are most frequently 
aff'ected. 

Inflammatory complications occur, as a rule, during the active period of 
rheumatism, when the inflammation is passing from joint to joint. If the 
general symptoms begin to improve and no new joints are involved, the 
liability to complications is greatly diminished. 

Pathology. — The joints aff'ected by rheumatism present various grades 
of inflammation, but in all typical cases, however intense the inflammation, 
suppuration does not occur. In a paper read before the London Medical 
Society, April 9, 1888, Dr. Money stated that when suppuration does occur in 
rheumatism the disease is complicated with sepsis, and Sir Wm. MacCormac 
and Dr. Ord expressed a similar opinion. 

Acuteness of sensation is increased over the inflamed joint. The ana- 
tomical changes in the joints have been sufficiently described in our remarks 
relating to the symptoms. Recently several writers have called attention to 
the fact that nodules occasionally occur under the skin in rheumatism. 
Lindmann relates two cases, an adult and a child, in which during the course 
of rheumatism numerous nodules appeared rapidly under the skin. They 
were about the size of a pea, hard, movable, and painful, but without red- 
ness. They disappeared during convalescence. Lindmann collated the rec- 
ords of 59 rheumatic cases in which nodules occurred. A majority of them 
were females, and 46 were children. These bodies usually appeared suddenly 
in the later stages of rheumatism, and varied from the size of a pin's head 
to that of an almond. They continued from a few days to a month or longer 
(Deutsche medin. Wocli.. p. 519, 1888\ Examination with the microscope 
shows that they consist of newly-formed connective tissue, such as results 



508 



ACUTE RHEUMATISM. 



Fig. 31. 



from inflammation (A^ner. Jour, of Med. Sci., Oct., 1888). G-arrod states that 
these nodules and muscular atrophy sometimes occur in the most simple forms 
of hydrarthrosis, and are usually attended by an increase in the reflexes, sug- 
gesting an excitability of the spinal cord (Loncl. Lane, June 2, 1888). It is 
stated that Charcot and Parisot also attribute the occurrence of these nodules 
to an exaggerated excitability of the spinal cord. On the other hand, Mayer 
and Cuilleret observed two cases of nodules and atrophy of certain muscles 

following an attack of arthritis, and 
they think that a true myelitis had 
occurred to produce such a result, along 
with the constant peripheral irritation 
(^Lyons Medical, Apr. 29, 1888). Homan 
relates the case of a patient aged eigh- 
teen years who had rheumatism of the 
muscles of the left leg from the hip to 
the ankle, lasting several weeks. In 
the latter part of his sickness the calf 
of the leg became unusually tender, and 
a hard nodule occurred in the muscular 
substance, and was accompanied by 
atrophy of the muscular fibres. The 
nodule gradually subsided and disap- 
peared (*SV. Louu Courier of 3Ird., 
March, 1888). The above observa- 
tions, to which more might be added, 
show that the anatomical characters of 
acute rheumatism are not restricted to 
the joints and heart, but subcutaneous nodules, and more or less muscular 
atrophy, occasionally occur. Cheadle says the nodules occur mostly in the 
neighborhood of joints, and that they are rare in adults, but very common in 
children. They develop within a few days, and sometimes in successive crops, 
" but they usually take many weeks to subside." The above figure represents 
these nodules as seen by Dr. Cheadle in a boy of four years. 




'';Uv;. 



Fig. 32. 






IN^^>-.;, . 


■ ^: ■ ,: 




^ - ^t 


iir^rr %. 


~:',5 ' 'i 


fe 


\ ■ ; ''\0 


.^.-.O-^.- -. r*- 


':-■.' ■ "-.^■■1. 




''t£&::;^xi':a 


-■ . ;:-:-\^-- 






;.^fl?:fey 


- ;i^-~^': . 






-j^;M^:^^^ 


^^>f^ . 






■M^.S'^&\i 


'if*^-'C-L~-'^ 


■"'•■i,.' 


1,'^'-f,>~ 









■^-u;-v- 



The woodcut (Fig. 32) shows the microscopic appearance of a nodule from a 



DIAGNOSIS. 



509 



Fig. 33. 



child of seven and a half years, as observed by Dr. Cheadle ; it exhibits the 
active cell-infiltration and proliferation of fibrous tissue : 

Duration ; Prognosis. — With proper treatment and without complica- 
tion the febrile action in a few days begins to abate, and the disease com- 
monly terminates within two weeks. Its duration is ordinarily shorter than 
in rheumatism of the adult. Fluctuations, however, are liable to occur. 
The disease may appear to be abating and the articular inflammations nearly 
cease when they return for a time, often without new exposure and without 
appreciable cause. The prognosis, even when cardiac inflammation has super- 
vened, is in most cases favorable, except so far as the lesion resulting from 
this inflammation is concerned, which being permanent may entail much sub- 
sequent suff'ering and occasion death after months or years. Indeed, what 
is most to be dreaded in cases of acute rheumatism is 
valvular disease or pericardial adhesion with its remoter 
consequences — namely, hypertrophy of heart, conges- 
tion and oedema of lungs, dropsies, etc. 

Secondary rheumatism occurring in scarlet fever is 
sometimes also complicated with, or rather coexists 
with, cardiac inflammation, pleuritis, or pneumonitis, 
rendering the prognosis more unfavorable. 

In rare instances the acute symptoms of rheuma- 
tism abate, but the joints remain stiff" and more or 
less swollen and painful when moved. The acute has 
lapsed into a subacute or chronic rheumatism. Such 
a case, represented in the accompanying figure, was 
brought to the children's class in the Out-door Depart- 
ment at Bellevue Hospital in February, 1871. E. 
H , a female three and a half years old, had inter- 
mittent fever from the age of nine to fifteen months. 
From this time she remained well till the age of two 
years, when she was taken with acute rheumatism, 
commencing in her ankles and extending to other 
joints. The knee- and hip-joints on both sides have 
only partially recovered their mobility, and both legs 
and both thighs are permanently flexed, so that the gait 
is slow and unsteady. It is impossible to straighten 
either limb without causing great pain, and attempts to straighten the thigh 
produce the arch in the back very similar to that in coxalgia. 

Diagnosis. — This is not difficult in ordinary cases if a proper examina- 
tion be made. In the commencement, if the aff"ection of the joints be 
slight, rheumatism might be mistaken for remittent, typhoid, one of the 
eruptive fevers, or meningitis ; but on careful examination tenderness of one 
or more of the articulations will be observed, and probably some swelling. 
This tenderness is readily distinguished from the hyperaesthesia which is 
common in the first stage of the essential fevers, and which is observed when 
pressure is made upon the chest or abdomen as well as upon the limbs, and is 
more marked between the joints than in them. Any doubt which may at first 
exist whether the patient may not have one of those diseases is soon dispelled, 
since their clinical history presents notable differences from that of rheumatism. 

I have known scrofulous arthritis or scrofulous osteitis near the joint 
present so close a resemblance to acute rheumatism as to be at first mistaken 
for it. In one instance this inflammation commenced nearly simultaneously 
in three joints, rendering the diagnosis at first very difficult. But scrofu- 
lous inflammation, as well as that from pyaemia, can be diagnosticated from 
rheumatic disease of the joints by its greater persistence, less induration 




510 ACUTE RHEUMATISM. 

and symmetry in the swelling, and by the history of the case. Chronic 
rheumatism may produce deformity similar to that from chronic scrofulous 
inflammation, as in the case mentioned above, but the rheumatic history, 
number of joints affected, bilateral character of the inflammation, good gen- 
eral health, etc. are sufficient to establish a clear diagnosis when the disease 
has been observed for some days. 

Treatment. — The treatment of acute rheumatism has undergone 
marked variations in the last thirty years. Its speedy cure is urgently 
demanded, on account of the imminent peril to the heart. From 1847 until 
a recent period the alkaline treatment, by the bicarbonate of potassium and 
bicarbonate of sodium, the tartrate of potassium and sodium, and the citrate 
of potassium, was commonly employed to the extent of rendering the urine 
alkaline in twelve or twenty-four hours. Statistics appeared to show that 
the duration of rheumatism was abridged by the alkaline treatment, and the 
liability to cardiac complications was diminished as soon as the urine became 
alkaline. Garrod reported 50 cases in which the average duration was six 
or seven days under the alkaline treatment. Fuller in 1862 stated that in 
no single instance in 194 cases did cardiac complications occur when the 
alkaline treatment had been employed twenty-four hours. Dickinson's sta- 
tistics also furnished strong evidence of the usefulness of alkalies in large 
doses, given so as to render the urine alkaline in twelve to twenty-four hours. 
He also stated that the alkaline treatment was inadequate unless employed 
so as to render the urine alkaline. More recently, the late Prof. Austin 
Flint considered the evidence conclusive in regard to the efficacy of the 
alkaline treatment of rheumatism, the doses employed being so large that the 
urine becomes alkaline in twenty-four hours. 

But since 1875 a new and, in acute cases of rheumatism, a very efficient 
remedy has come into use — to wit, salicylic acid or its compound, salicylate 
of sodium. The sodium salicylate is most frequently employed. It may be 
given every two hours to adults in doses of ten to twenty grains, and to 
children in proportionate doses. But, although salicylic acid or salicylate 
of sodium acts almost as a specific in recent cases of rheumatism, relieving 
the pain and fever and diminishing the articular inflammation, it often pro- 
duces certain ill effects. It impairs digestion, causing nausea, and sometimes 
vomiting. It produces tinnitus aurium, and sometimes headache or vertigo, 
and occasionally albuminuria, as I have several times observed, so that it 
should not be employed longer than is required to control the rheumatism. 
The employment of salicylic acid or salicylate of sodium does not, apparent- 
ly, prevent cardiac or other complications, and it is probably best to adminis- 
ter it in combination with, or alternately with, an alkali. 

The following formula is essentially that which has been employed in the 
Out-Door Department at Bellevue with apparently excellent results : 

R. Acidi salicylic, .^ij~iij ; 

Potas. acetat., .^ss ; 

Glycerinse, Jj ; 

Aquse, q. s. ad ^v. Misce. 

Give one teaspoonful every two or three hours to a child of six years. 

An eligible vehicle for the sodium salicylate is the syrup of raspberry, 
as in the following formula : 

R. Sodii salicylat., ^iij ; 

Rodii bicarbonat., ^iy, 

Syr. rubi idsei, ,§ij ; 

A quae, ,^iij. Misce. 

Give one teaspoonful every two or three hours to a child of six years. 



TREATMENT. 511 

Since the oil of wintergreen contains a considerable amount of salicylic 
acid, it has been sometimes employed, as in the following formula : 

R. 01. gaultheriffi, 5j;_ 

Sodii salicylat., .^iij ; 

Syr. simplic. Jiij ; 

Aquae, ^vj. Misce. 
Dose : A dessertspoonful to a child of five years. 

During the declining period of rheumatism and in convalescence quinine 
or some preparation of cinchona should be employed and the above medi- 
cine given less often. This tonic does indeed appear to exert a beneficial 
effect on the course of rheumatism, and is employed by some judicious and 
experienced physicians from the commencement. 

If there be a high temperature and a quick pulse, quinine administered 
in an occasional large dose will be found very useful. Three to five grains 
may be given to a child of five years. 

Rheumatism impoverishes the blood, and the patient often begins to 
present an anaemic appearance, when he requires iron in addition to the veg- 
etable tonic. The citrate of iron and quinine may then be employed. 

Secondary rheumatism requires sustaining treatment from the first. 
Such cases ordinarily do well without antirheumatic treatment, with the gen- 
eral supporting measures employed for the primary disease. 

Antipyrine has recently been prescribed in adult cases during the acute stage 
with such marked relief of the pain and reduction of temperature that it prom- 
ises to be a valuable remedy. Frankel administered it to 34 patients between 
the ages of fourteen and twenty-eight years in doses of fifteen grains every 
three hours. In 2 of the cases it disagreed, and was discontinued. In the 
other cases it speedily relieved pain and reduced the fever (^Deutsche med. 
Woch., 1887). Dr. N. S. Davis, Sr., obtained equally favorable results from 
the use of antipyrine, but relapses and cardiac complications occurred in 
about the same proportion of cases as during the use of the salicylates. 
Antipyrine has not yet been sufiiciently employed in the treatment of 
rheumatism of children to determine its value or safety. 

Salol has also been largely used in adult cases during the last two or 
three years, but Rosenberg of Berlin states that it produces all the unpleas- 
ant efi"ects of the salicylates, and does not appear to be any more efiScacious 
in the treatment of rheumatism. Dr. Lombard of Paris believes that it is 
resolved into salicylic and carbolic acids in the system, and unless this 
decomposition occurs it is inert. He believes that its value has been over- 
estimated in the treatment of rheumatism. Salol, if administered to chil- 
dren, should certainly be given in small doses, on account of the danger of 
poisoning from the carbolic acid in its composition. It will therefore proba- 
bly not come into use as a remedy for the rheumatism of children. 

Pneumonitis complicating rheumatism is best treated by moderate coun- 
ter-irritation and emollient poultices and the internal use of carbonate of 
ammonium or quinine. In pericarditis or endocarditis if, as is commonly 
the case, the movements of the heart be accelerated, aconite or the tincture 
or infusion of digitalis is demanded to the extent of reducing the number 
of pulsations to near the normal frequency. A child of six years can take 
three drops of the tincture or a large teaspoonful of the infusion, to be 
repeated, if necessary, in three hours till the reduction of the pulse is efi"ect- 
ed. Patients often experience relief by the use of this agent from the pal- 
pitation and dyspnoea consequent upon the embarrassed movements of the 
heart. If the heart disease be severe and pulse feeble, quinine is also use- 



512 ERYSIPELAS. 

ful. The tincture of strophanthus or that of spartein is sometimes pre- 
scribed as a substitute for the digitalis. 

The patient should be kept quiet in a room of uniform temperature, and 
not exposed to draughts of air. By such precautions the danger of compli- 
cations is greatly diminished. Repellant applications, as cold or irritants, 
should not be applied to the joints so long as the disease is acute, for they 
also increase the danger of complications. The affected joints should be 
enveloped in flannel or cotton, and the pain, if intense, may be diminished 
by applying flannel wrung out of warm water. If the disease become 
subacute or chronic, if the urates have disappeared from the urine, and the 
inflammation cease to pass from joint to joint, the tincture of iodine or mod- 
erately stimulating embrocations applied to the joints involve no danger and 
are useful. 



CHAPTER yi. 
EEYSIPELAS. 

The term " erysipelas " is applied to a constitutional or blood disease 
which is characterized by inflammation of the skin and subcutaneous connec- 
tive tissue and a tendency to spread. It is accompanied by pungent and 
pricking heat, swelling, and subcutaneous infiltration. 

In rare instances, in young infants, an inflammation which has been desig- 
nated erysipelas occurs in and around the umbilicus. It commences about 
the time of the detachment of the umbilical cord, and is accompanied by 
redness of the skin and tumefaction, with induration of the connective tissue 
surrounding the umbilicus. It usually causes ulceration of the umbilical 
fossa, and in fatal cases pus is sometimes found in the umbilical vessels. 
This disease does not show any tendency to spread ; the diameter of the 
inflamed surface is not more than three or four inches, with the umbilicus at 
the centre. It is generally fatal, but two favorable cases have been reported 
to me, in one of which there was considerable ulceration, and after recovery 
a firm cicatrix occupied the site of the umbilicus. The most reasonable view 
is that this disease is primarily an inflammation of the umbilical fossa and 
vessels induced by uncleanliness, cachexia, or other cause. It lacks the dis- 
tinguishing feature of erysipelatous inflammations — namely, the tendency to 
spread — and I shall therefore take no further notice of it in this connection. 
(See Diseases of the Umbilicus.) 

Erysipelas occasionally occurs in childhood ; the cases which are met in 
this period present nearly the same features and pursue nearly the same 
course as in the adult. In infancy erysipelas is a common disease, and the 
following remarks relate chiefly to erysipelas occurring in this period of life. 
They are based on data derived mainly from the records of cases which 
occurred in this city, some in my own practice, and others in the practice of 
physicians known to be good observers. The points of chief interest in 41 
cases are embraced in the opposite table : 



TABLE OF CASES. 



513 



Cases of Infantile Erysipelas. 



6 


i\ ^- 


i Point of 
1 commencement. 


Parts affected 


Duration. 


Result. 


1 


M. 5 mouths. 


Right knee. 


Entire surface, except face and scalp. 


5 weeks and 

8 days. 
7 days. 


Recovered. 


2 


M. 2 years. 


Left knee. 


From a little above the knee to the 


Recovered. 




1 




ankle. 






3 


M. 10 months. 


Elbow. 


Whole arm and forearm. 




Recovered. 


4 


F. 20 


Below right knee. 


Entire leg, thigh, and trunk to the 
umbilicus. 


7 days. 


Recovered. 


5 


F. 9 " 


Vulva. 


Abdomen, chest, and all the ex- 
tremities. 


18 " 


Recovered. 


6 


M. 9 days. 


Genitals. 


Both lower extremities, abdomen to 
the umbilicus. 


6 " 


Died. 


7 


F. 1 year. 


Vulva. _ 


Entire surface, except face. 


6 weeks. 


Recovered. 


8 


F. 6 weeks. 


At or near the ear. 


Forehead and side of face. 


1 week. 


Died in tetanic 
spasms. 


9 


. . 9 months. 


Epigastric region. 


Trunk and lower extremities. 


2 weeks. 


Died in tetanic 
spasms. 


10 


F. 10 " 


At angle of mouth. 


Entire face and scalp. 


10 davs. 


Recovered. 


11 


F. 4 weeks. 


Vulva. 


Entire surface, except face. 


3 weeks. 


Died. 


12 


F. 3 months. 


Vulva. 


Surface of abdomen to umbilicus and 
right lower extremity. 


•2 


Recovered. 


13 F. 4 to 5 mos. 


Vulva. 


All the limbs and trunk, except the 


3 to 4 weeks. 


Died. 








chest. 






14 


F. 5 months. 

, 1 

F. j3 " 


From syphilitic 
sores around anus. 


Trunk and both lower extremities. 






15 


Vulva. 


Entire trunk and both upper ex- 


3 weeks. 


Recovered. 








tremities. 






16 M. 8 " 


Face near nostrils. 


Entire trunk and both upper ex- 
tremities. 


About 2 
weeks. 


Recovered. 


17^ F. 4 " 


Vulva. 


Entire trunk and all the extremities. 


1 week. 


Died. 


ISF. 7 " 


Knee. 


A portion of trunk and both lower 

extremities. 


3 weeks. 


Recovered. 


19 F. 6 » 


Near the ear. 


Entire face and forehead. 


10 days. 


Recovered. 


20 


M. 7 days. 


Left eyelid. 


Left side of face. 


3 '• 


Died. 


21 


M. 14 " 


Genitals. 


Extended to knee, over abdomen to 
the chest. 


4 " 


Died. 


22 


M. 


3 months. 


L'lnder the chin. 


Chin, left cheek, neck, left side of 
trunk, left thigh and leg. 






23 


F. 


28 " 


Right shoulder. 


Arm and forearm. 


1 day. 


Died in convul- 
sions. 


24 


F. 


3 or 4 days. 


Vulva, 


Body and all the limts. 


12 days. 


Died. 


25 


F. j 33^ mos. 

j 


Under left ear. 


Neck, chest, and arms. 


About 2 
weeks. 


Died. 


26 


. . |7 months. 


Below right knee. 


Trunk, neck, and head, and all the 
limbs. 


2 weeks. 


Died comatose. 


27 


F. 6 " 


Vulva. 


Both thighs and nearly entire trunk. 


3 davs. 


Died comatose. 


28 


M. 19 " 


Near point of 


Shoulder, arm, and forearm. 


21 '"' 


Recovered. 








vaccination. 








29 


M. 


4 


Near point of 
vaccination. 


Chest and both upper limbs. 


2 weeks. 


Recovered. 


30 


F. 


2 " 


Near vaccine 
Tesicle. 


Trunk and all the limbs. 


10 days. 


Died. 


31 




3 to 4 mos. 


Near vaccine 
vesicle. 


Arm, forearm, and shoulder on one 
side. 


2 to 3 weeks. 


Died. 


32 


F. 


4 months. 


Near vaccine 
vesicle. 


Arm, forearm, and trunk. 


2 months. 


Died. 


33 


M. 2 


Near vaccine 
vesicle. 


Nearly entire surface. 


1 week. 


Died with peri- 
tonitis. 


34 


M. 51^ " 


^ear point of 
vaccination. 


Arm and forearm. 


1 


Recovered. 


35 


M. 23^ " 


Near point of 
vaccination. 


Arm. 


7 days. 


Died probably 
of peritonitis. 


36 


M. 8 


Near vaccine 
vesicle. 


Arm and forearm. 


17 " 


Died. 


37 


. . 5 

1 


Left foot. 


Leg, thigh, and lower part of trunk. 


2 weeks. 


Died with 
pneumonitis. 


38 


. . 5 weeks. 


At one ear. 


Entire surface. 


2 


Recovered. 


39 


. . i2 months. 


Left leg. 


Trunk and all the limbs. 


2 


Recovered. 


40 


. . !4 


Near point of 
vaccination. 


Trunk and all the limbs. 


2 


Died. 


41 


M. 


14 " 


Face. 


Trunk and all the limbs. 


4 


Recovered. 



Age. — Of the above cases, 27 were under the age of six months, 9 from 
six months to twelve, and only 5 above the latter age. A large majority, 
therefore, of cases of infantile erysipelas occur in the first year of life. 

Point of Commencement. — In 58 cases in which I have ascertained 
the point of commencement it was in 13 cases the vulva, 17 the arm after 
33 



514 ERYSIPELAS. 

vaccination, 7 the leg, 6 the face, 8 the male genital organs, 3 at or near the 
ear, 1 the elbow, 1 the shoulder, 1 the nates, 1 the foot. In the adult, idio- 
pathic erysipelas commonly commences upon the face and affects only the 
face, ears, forehead, and scalp. On the other hand, in infantile erysipelas 
statistics show that the rash commences upon the face only in a small pro- 
portion of cases, 1 in 9, and that it rarely extends to the face when it com- 
mences in other parts. 

Causes.— The fact that erysipelas is infectious has led to many micro- 
scopic examinations in order to discover the nature of the microbe which 
causes it. In most instances some injury of the surface has occurred through 
which the poison is received — a scratch or abrasion or a slight cutaneous 
eruption. Many instances have been cited showing infectiousness. In my 
practice a child contracted it from lying in bed with one of the family 
who had facial erysipelas. The following cases were related before the Paris 
Academy in 1864: Dr. Paintevin contracted erysipelas from two cases occur- 
ring in a hospital ward, and was visited by Dr. Testart of Guise, a place free 
from erysipelas. Three days after returning home this physician sickened 
with erysipelas. His servant, who waited on him, and a relative living twen- 
ty-four miles away, who called on him, also contracted the disease. The 
relative's wife was then seized with it, and also three members of a family 
who had called upon them. These last patients communicated the disease 
to a relative and two Sisters of Mercy who nursed them. These sisters, 
returning to the convent, infected others, among whom was the physician of 
the convent, who died. The ph^^sician's daughter also contracted it, the 
inflammation beginning in leech-bites which had been made over enlarged 
glands. Infectiousness has been shown not only by clinical experience, but 
also by experiments ; small tumors have been successfully inoculated with 
cultures of the erysipelatous cocci, but some of the patients thus treated 
have died. The attempt to remove tumors by inoculating them with the 
erysipelatous virus shows the highly infectious character of erysipelas, and 
certain small tumors have been removed by the erysipelas, while in other 
instances the result has been disastrous, death occurring. 

Fehleisen has discovered the specific microbe of erysipelas — to wit, a 
streptococcus or chain-coccus, which he has cultivated, and by inoculating 
the cultures he has been able to reproduce erysipelas in tumors. More 
recently Meerovitch made microscopic examinations in thirty-one cases of 
erysipelas, and invariably found a large number of these streptococci in the 
affected skin, and in grave cases also a few in the blood. He detected this 
organism in abscesses and in fatal cases likewise in internal organs. The 
cultures made in meat bouillon preserved their vitality four or five months. 
It is now known that this organism sometimes passes from the maternal 
organism to the foetus through the uterine circulation. Ziegler says that the 
micrococcus which causes erysipelas enters the lymphatics and spreads chiefly 
by them. They are found, says he, in immense masses or swarms in the lym- 
phatics, and from them they spread into the tissues, where they excite inflam- 
mation and often tissue-necrosis (Lond. Med. Recorder, Nov. 20, 1888). 

The blood may undergo certain changes which predispose to erysipelas or 
render the system less able to resist the micrococcus. Among the causes which 
produce this state of system, uncleanliness, residence in damp, dark, and 
crowded apartments, and defective alimentation hold a principal place. 
Hence this disease is more common in the poor quarters of a city than in 
the country, and in dispensary and hospital than in family practice. 

In a large proportion of cases there is an irritation or inflammation at 
some point, generally trivial, through which the streptococcus enters the 
syste-m. Erysipelas therefore commonly begins at a simple ecthymatous or 



PREMONITORY SYMPTOMS. 515 

impetiginous eruption, around burns or suppurating sores or syphilitic erup- 
tions ; it frequently commences, as is seen by the above table, near the point 
of vaccination immediately after vaccination or when the pock is developed, 
or again when it has run its course and been detached. In a considerable 
proportion of cases it begins at the point where the skin is thin and delicate, 
or where it unites with a mucous surface, probably produced by some unclean- 
liness or irritation of those parts. Thus, I have records of cases in which it 
commenced at the external ear, commissure of the mouth, and at the vulva. 
Indeed, the frequency with w^hich it commences at the vulva renders female 
infants more liable to it than males. In some instances erysipelas begins 
without any local exciting causes upon smooth and sound skin, even when 
there are sores upon various points of the surface. 

Vaccination, as an exciting cause of erysipelas, demands particular notice. 
Often, doubtless, it is the inflammation which necessarily arises from the cut 
or vesicle which operates as an exciting cause of the erysipelatous affection, 
and not any deleterious propeity contained in the virus which is employed, 
so that an equal degree of inflammation occurring in any other way, as from 
a burn, would be attended by a like result. But facts show that the virus 
itself occasionally contains a latent noxious principle, which, introduced into 
the system, operates as a cause of erysipelas. Thus, a little girl was vacci- 
nated by me in November, 1860, and about the time when the vesicle began 
to fill she was seized with severe inflammation of the fauces, attended by tume- 
faction and infiltration of the submucous connective tissue. The inflammation 
rapidly subsided, and within a week from its commencement the throat aifec- 
tion had nearly disappeared. I now believe that the disease of the fauces 
was erysipelatous, although it was not suspected at the time to have this 
character. 

As the girl was otherwise healthy and the vaccine vesicle passed through 
its usual stage and presented the usual appearance, the scab was employed 
six weeks afterward to vaccinate two infants. Within twenty-four hours after 
vaccination both these infants were seized with high fever, ushering in severe 
erysipelas, commencing in one around the point of vaccination, and in the other 
around syphilitic sores near the anus. In the former case the er3^sipelatous 
rash extended from the shoulder over the entire limb, and was obstinate, twice 
reappearing and extending over the same surface ; in the latter (a mulatto 
child) it extended over both lower extremities and a considerable part of the 
trunk, when the case passed into the hands of another physician, and the result 
is not known. The instrument with which the vaccinations were performed 
was clean. The vaccine disease did not appear in either of these cases. 

Again, a well-known physician of this city vaccinated three infants, one 
his own (No. 32 of the table), with part of a scab which had been pronounced 
good, but was taken from a child that he had not seen and with whose state 
he was not familiar. These infants were all aff"ected with erysipelas from the 
vaccination, his own dying. He had taken the precaution to rub the lancet 
on his boot before using it. Another physician of this city has informed me 
that he vaccinated two children in the same family with a scab, with all the 
precautions that he ever had used, and both were soon after afi"ected with ery- 
sipelas of a severe form, extending from the point of vaccination ; the vaccine 
disease did not appear. I have heard of no case in which the vaccine lymph 
gave rise to erysipelas, and probably it rarely or never does. In the lymph 
there is no admixture of foreign substances, whereas in the scab there is a 
large proportion of animal matter. 

Erysipelas neonatorum is treated of in our remarks on Sepsis of the New- 
born, page 143. 

Premonitory Symptoms. — Infantile erysipelas in certain cases has no 



516 ERYSIPELAS. 

premonitory stage, or, if present, it escapes notice. In other instances there 
are well-marked precursory symptoms, as drowsiness or restlessness, more or 
less fever, oppressed respiration, with perhaps vomiting and sudden twitching 
of the limbs. In Cases 28 and 37 of the table, which occurred in my prac- 
tice, the fever, restlessness, and dyspnoea were so great for three days before 
the appearance of the eruption as to cause much anxiety. In the adult 
erysipelatous patient, pharyngitis often precedes the occurrence of the rash 
upon the skin. The same inflammation may be present in the premonitory 
period of infantile erysipelas, as well as during the period of erysipelatous 
eruption. The hurried and difficult respiration which is present in the com- 
mencement of some cases is probably due to an erysipelatous turgescence 
of the bronchial mucous membrane. 

Symptoms. — The patient with this disease is usually restless in conse- 
quence of the burning pain which accompanies the eruption. In severe cases 
there is little sleep, night or day, except from medicine. The sleep is short, 
and is often interrupted by sudden starting or twitching of the limbs. Con- 
vulsions may occur, but are not common. 

Fever is constantly present, and is proportionate to the extent and grav- 
ity of the erysipelas. I have notes of cases in which the pulse was more 
than 200 per minute, although other symptoms did not indicate immediate 
danger. The skin not affected by erysipelas is dry and hot, though not pos- 
sessing the pungent heat of the inflamed portion ; face often flushed ; tongue 
moist and covered with a light fur ; stomach usually retentive. The state 
of the bowels varies ; sometimes they are regular, sometimes variable, and 
in other cases the stools are green and more frequent than natural. I have 
records relating to the state of the bowels in 20 cases, as follows : in 7, regu- 
lar ; in 9, loose; in 2, constipated: in 1, constipated, then loose; and in 1, 
constipated, then regular. Diarrhoea, when present, is usually mild, requir- 
ing little or no treatment. The erysipelatous redness is not in all cases so 
pronounced as in the adult, but otherwise there is nothing peculiar in its 
appearance. In feeble infants with an impoverished state of the blood its 
color is pink, instead of the deep red which characterizes the inflammation 
in the robust. Points of vesication may occur where the inflammation is 
most severe, as in the adult, and subsequently the same desquamation and 
oedema. 

If the infant be debilitated there is great danger of the formation of 
abscesses around which the inflammation lingers after it has disappeared from 
every other part of the body. Sometimes also in very young infants gan- 
grene occurs, especially in the genital organs in the male. Several of these 
cases have been related to me, all under the age of a month or six weeks, 
and all fatal. Occasionally the sloughing is so great as to denude the testicle. 
A noteworthy feature of erysipelas in infants is its proneness to return. 
When it has been progressively subsiding and hope is entertained of its speedy 
disappearance, it not infrequently is suddenly relighted from some unknown 
cause, travelling again over the same or parts of the same surface. In one 
case the disease, arising from vaccination, extended three times over the arm' 
and forearm ; and in another case a second time over both legs and a consid- 
erable part of the trunk. 

The internal inflammations which most frequently complicate erysipelas 
and give rise to symptoms which are superadded to those pertaining to the 
erysipelas are pharyngitis and peritonitis, and more rarely broncho-pneumonia 
or enteritis. In a case which I examined after death in the Nursery and 
Child's Hospital, and in which, the erysipelatous inflammation having extended 
over the abdomen, the lesions of peritonitis were present, it appeared from 
the thinness of the abdominal walls that the inflammation had extended 



PROGNOSIS— PATHOLOGICAL ANATOMY. 517 

through them from the external to the internal surface or from the skin to 
the peritoneum. 

Prognosis. — Erysipelas is much more fatal in infancy than in adult life. 
In the death-statistics of this city for three years I find 80 deaths from ery- 
sipelas of infants under the age of one year to 83 deaths from this disease 
above that age. Age greatly influences the prognosis. Infants under the 
age of three weeks usually die ; from the age of three weeks to six months 
the result is doubtful ; while above the age of six months a majority recover 
with correct treatment. It will be seen by the foregoing table that 7 infants 
under the age of six weeks had erysipelas, and 6 died ; from the age of six 
weeks to six months, 6 recovered and 9 died ; and above the age of six months, 
9 recovered and 4 died. 

With the exception of a case of the so-called umbilical erysipelas, the 
youngest child who recovered of whom I have obtained information was 
three weeks old. In this case the rash extended nearly over the entire sur- 
face, beginning with the face. Case 38 of the table, treated by myself, was 
very similar as regards the extent of the erysipelatous eruption and the 
result. This infant was five weeks old. 

It is scarcely necessary to state that erysipelas is more favorable when 
it affects the limbs than when it invades the head, neck, or body ; when it 
spreads slowly than rapidly ; when it is superficial than when phlegmonous. 
In those cases in which the connective tissue is much involved the infant 
is not always safe after the disease has run its course ; he sometimes dies 
exhausted from the discharge of abscesses; I have records of two such 
cases. 

Duration. — In 16 cases that recovered the erysipelas terminated within 
the first week in 2, the second week in 6, the third week in 5, fourth week in 
1, and in 2 cases it lasted five and six weeks. The average duration was 
fifteen days. In 19 fatal cases, 10 died within the first week, 5 the second 
week, 3 the third week, and 1 in the fourth w«ek. The average duration of 
fatal cases was about ten days. 

Modes of Death. — Death occurs in different ways : in chronic or tonic 
convulsions followed by coma, from exhaustion, and from internal inflamma- 
tion, that from exhaustion being probably the most common. 

Pathological Anatomy. — The blood doubtless in this disease under- 
goes certain pathological alterations previously to the occurrence of the erup- 
tion, but the exact changes are not known. Our knowledge of the morbid 
anatomy of erysipelas relates chiefly to the local affections, which, with the 
exception of the inflammation of the skin, are not constant, and may there- 
fore be regarded as complications. The cutaneous inflammation affects all 
the structures of the skin, and in greater or less degree also the subcutaneous 
connective tissue. The inflammation is accompanied by more or less serous 
effusion or oedema. 

The not infrequent occurrence of peritonitis in connection with erysipelas 
has long been known. In Heberden's Epitome Morhonnii Puerilium the 
anatomical character of erysipelas is expressed in one sentence : " When the 
body has been opened after death the intestines have been found glued 
together and covered with coagulable lymph." Since Herberden's time 
nearly all who have written on diseases of infancy and childhood have men- 
tioned peritonitis as one of the most common complications of erysipelas. 
Underwood says: "Upon examining several bodies after death the contents 
of the body have frequently been found glued together and their surface 
covered with inflammatory exudation, exactly similar to that of women who 
have died of puerperal fever." Similar remarks in reference to the frequency 
of peritonitis in this disease are made b}" recent writers. 



518 ERYSIPELAS. 

The statistics in reference to erysipelas as well as peritonitis show that in 
infants in hospital practice, and in those aiFected by erysipelas during epi- 
demics of puerperal fever, peritonitis is a not infrequent complication. On 
the other hand, as we commonly meet cases of infantile erysipelas occurring 
sporadically in private practice, abdominal distension and tenderness are not 
sufficient to indicate peritonitis. In only one of the cases embraced in the 
foregoing table was a post-mortem examination made, and in that there had 
been no peritonitis. The occurrence of pharyngitis in connection with ery- 
sipelas has been already mentioned. 

Enteritis has been alluded to as another complication in infants. Diar- 
rhoea has been stated to be a symptom in certain cases, and it has been found 
to be dependent on enteritis of a mild grade. Billard made post-mortem 
examinations of 16 infants who died of erysipelas, and " found in 2 gastro- 
enteritis, in 10 enteritis, in 3 pneumonia complicated with enteritis and cerebral 
congestion, and in 1 pleuro-pneumonia." 

Prophylaxis. — A patient with erysipelas should be isolated, and the 
bedding and linen worn by him should be placed in boiling water as soon as 
removed. No one should be allowed to occupy the bed or room when vacated 
by the patient until it has been thoroughly disinfected. 

Treatment. — The external treatment has varied greatly, but those agents 
are now most employed which have soothing or antiseptic properties. Among 
them we may mention iodoform in collodion. Trousseau employed an ethereal 
solution of camphor and tannin. Scarification and leeching, formerly employed, 
have been abandoned as pernicious, and astringents, as alum and sugar of 
lead, are now known to be inefficacious. Strong counter-irritation over the 
inflamed surface has also been practised. Baron Larrey applied the actual 
cautery, and since his time nitrate of silver, one part to ten, has been used, 
but without appreciable benefit. The solid nitrate of silver was employed in 
two cases of which I have the records, and in both the result was pernicious. 
Troublesome sores were produced, from which blood flowed, and in one of 
the cases the parents attributed the death to this treatment, rather than to 
the primary disease. The tincture of iodine is preferable to the nitrate of 
silver for local treatment. It should be applied in officinal strength over the 
inflamed surface and to the distance of two inches upon the sound skin. It 
may fail in arresting the extension of the erysipelas, but it does not produce 
any unfavorable result. Carbolic acid is a better antiseptic agent for local 
treatment, solutions of which are known to be absorbed, by the olive color 
imparted to the urine. It should not, however, be applied in young children 
over a great extent of surface, on account of the danger of carbolic-acid 
poisoning. Tillmann and Fehleisen ascertained that cultures mixed with 2 
to 4 per cent, of carbolic acid were sterilized. Verneuil sprayed the surface 
during five minutes every hour with a 2 per cent, solution of carbolic acid. 
Hueter made hypodermic injections of a 3 per cent, solution of carbolic acid, 
and found that a syringeful sufficed for two square inches. He employed 
as many as twelve syringefuls at one time, without, it is said, any unfavor- 
able result ; but probably it would be better to limit the number to two or 
three each day, to avoid the risk of carbolic-acid poisoning. The application 
may also be made with surgeon's lint constantly saturated with a 2 to 4 per 
cent, solution of carbolic acid in glycerin and water. Wilde employs, inas- 
much as it involves less risk than the use of carbolic acid, one or two syringe- 
fuls of an 8 per cent, solution of the sodium sulphocarbolate. It is said 
that it immediately reduces the temperature, and the erysipelas disappears in 
three or four days. The use of turpentine externally also has its advocates. 
Luecke says that when applied upon the erysipelatous surface it reduces the 
fever and the burning. A mixture of one part of carbolic acid and ten of 



TREATMENT. 519 

turpentine has lately been recommended. Xussbaum recommends for exter- 
nal treatment one part of ichthyol to ten of vaseline ; and Lorenz. two parts 
of ichthyol to one part of glycerin and one of ether. Finally, hypodermic 
injections of corrosive sublimate have been lately used, the solution vary- 
ing from 1 part in 5000 to 1 part in 500. 

On this side of the Atlantic great uniformity prevails as regards the 
internal treatment of erysipelas. Sustaining measures are prescribed, and 
the tincture of the chloride of iron is the tonic generally preferred. What- 
ever the intensity of the febrile reaction and the stage of the disease, if there 
be no intestinal complication ferruginous or other tonics should be adminis- 
tered. The largest doses of the tincture of the chloride of iron given in any 
of the cases in the above table were in Case Xo. -4 — namely, ten drops every 
two hours — and this patient recovered in seven days from a pretty severe 
attack. Probably, however, nothing is gained by such large doses, and they 
may irritate the intestinal surface and increase the liability to enteritis, which, 
we have seen, complicates a certain proportion of cases. Four drops may be 
given every three hours to a child from one to two years of age. Instead 
of the iron, or in addition to it, one of the preparations of cinchona may be 
prescribed. 

Erysipelas being an asthenic disease, it is very important that the diet 
should be highly nutritious and easily digested. Milk, perhaps peptonized, 
should be given freely, and the various meat peptones are also useful. 
Brand}' or wine is also required. If vomiting be a pronounced symptom 
it may be necessary to employ rectal alimentation. 



PART IV 



SECTION I 



DISEASES OF THE CEREBRO-SPIN AL SYSTEM. 

Diseases of the brain and spinal cord are less frequent than those of the 
respiratory and digestive systems, and, being less amenable to treatment, they 
largely increase the aggregate of deaths. They contrast with the diseases of 
the other systems in their greater relative frequency in infancy and childhood 
than in adult life. This is explained, as regards the brain, by the rapid devel- 
opment and active molecular change in this organ in early life, its great im- 
pressibility by the emotions, and the thinness of the covering which protects 
it from external agencies. 

Some of the most important of the diseases of the cerebro-spinal system 
are peculiar to early life, as tetanus infantum and spina bifida. The dis- 
eases of this system also contrast with other local affections in their greater 
obscurity, especially in their commencement ; for, while maladies of the tho- 
rax can be readily ascertained by auscultation and percussion, or those of the 
abdomen by the nature of the evacuations or the degree of tenderness or dis- 
tension, our means of conducting examination through the bony encasement 
of the cerebro-spinal axis are meagre and unsatisfactory. The condition of 
the brain and spinal cord must be determined chiefly by the study of symp- 
toms, and not by direct examination. The state of the anterior fontanel 
in young infants, however, enables us to determine the presence or absence 
of active congestion of the brain. If there be an excess of arterial blood, 
it is convex. Prominence of the fontanel is common in inflammatory and 
febrile diseases, and is a sign of considerable diagnostic and prognostic 
value. 

Within a few years the ophthalmoscope has been employed as a means 
of diagnosis in cerebral diseases, and, although the use of this instrument 
for such purposes is but recent, enough has been elicited to prove its 
value as an aid in determining the state of the brain. Prof, H, D. Noyes 
remarks on this subject :...." The argument for making ophthalmoscopic 
examination in all cases of brain disease becomes irresistible. Indeed, a 
moment's reflection would lead to this conclusion without any considerations 
drawn from pathology. The optic nerve is only an outlying portion of the 
brain ; its extremity is fully exposed to view. Situated within about two 
inches of the brain, it is the only nerve in the body which we can inspect; 
it contains blood-vessels which communicate directly with the intracranial 
circulation. We thus come into relation with the cerebrum by continuity of 
nerve-structure and also of blood-vessels." 

Structural changes in the optic nerve and retina have been discovered by 
520 



DISEASES OF THE CEREBRO-SPIXAL SYSTEM. 521 

means of the ophthalmoscope in meningitis, hydrocephalus, phlebitis of the 
sinuses, apoplexy, etc. Among the lesions which have been observed by this 
instrument are hyperemia, more or less opacity and tumefaction of the optic 
nerve, engorgement of the vessels of the retina, with serous or sero-fibrinous 
exudation and ecchymotic points. In certain protracted diseases, as chronic 
hydrocephalus, in which dimness or loss of sight occurs, the ophthalmoscope 
discloses a state of atrophy of the optic nerve. Heretofore this instrument 
has been chiefly employed by oculists, but as it comes into more general use 
there can be little doubt that it will be recognized as an important aid in the 
diagnosis of obscure cerebral diseases. 

Still, with all possible aid to diagnosis, the obscurity which attends the 
invasion of many of the cerebro-spinal diseases must be acknowledged. To 
the hasty and careless physician their symptoms are often deceptive. Careful 
weighing of the phenomena and thorough and protracted examination are 
requisite in order to insure correct diagnosis and proper treatment. Some of 
the cerebro-spinal affections are, in reality, sequelae of other diseases — as, for 
example, spurious hydrocephalus — and some are, strictly speaking, only 
symptoms, as convulsions ; but on account of their importance, and because 
they require special treatment, it is proper to consider them as diseases jj^?' se. 

The brain presents certain peculiarities in infancy and childhood. In the 
foetus, while the other organs are well formed, the brain, especially its cerebral 
portion, is still diffluent, and at birth it has so little consistence that it must 
be handled carefully to prevent laceration. This softness is due to the large 
proportion of water which it contains. The following analyses show the 
composition of the brain in three periods of life : 

Infant. Youth. Adult. 

Albumen 7.00 10.20 9.40 

Cerebral fats 3.45 5.30 6.10 

Phosphorus ^ 0.80 1.65 1.80 

Osmazome, salts . 5.96 8.59 10.19 

Water 82.79 74.26 72.51 

At birth the brain has a nearly uniform white color. The gray substance, 
in which the nervous power originates, is undeveloped. The date of its 
appearance corresponds with the first exhibition of emotion or intelligence, 
and the decided gray color which we observe in the brain of the adult does 
not appear until the age of full mental activity. 

In the new-born the brain is large in proportion to the rest of the body, 
and its growth during infancy and childhood is rapid. Until the fifth year, 
as appears from the observations of Dr. Peacock, its weight is about one- 
seventh or one-eighth that of the entire system, the proportion varying some- 
what in different cases. 

The brain does not attain its full size, as stated by Dr. West, at the age 
of seven years, but, according to Dr. Peacock's statistics, it continues to 
increase till the age of twenty-five or thirty, although its growth is less rapid 
after the age of seven years than previousl3\ 

The membranous covering of the cerebro-spinal axis is scarcely less 
interesting to the pathologist than the axis itself. I shall speak in the 
following pages of the arachnoid and cavity of the arachnoid for convenience 
of description, although aware of the fact that some eminent authorities, as 
Virchow and Kolliker, whose opinions in reference to the minute anatomy 
of the system always command attention, if not assent, believe that there 
is no arachnoid, but what has heretofore been called by this name is on 
the one side the smooth surface of the dura mater and on the other of the 
pia mater. 



522 MICROCEPHALUS— ATROPHY OF BRAIN. 

The dura mater is seldom involved in the diseases of early life, except as 
it is affected by pressure, while the pia mater and arachnoid are the seat and 
source of some of the most important diseases, as meningitis, meningeal 
apoplexy, etc. 

The more complicated and delicate the structure of an organ the more 
liable it is to errors of nutrition and growth. There is, therefore, no organ 
which is so liable to irregular development as the brain. It may be entirely 
wanting, or it may be partially developed, certain portions being absent, or, 
lastly, its growth may be excessive, constituting hypertrophy. 



CHAPTER I. 

MICROCEPHALUS— ATROPHY OF BRAIN. 

An abnormally small brain usually results, according to my observations, 
from a defect in the foetal development. At birth the cranium is not only 
prematurely small, but the cranial bones are firmly united, so that the sutures 
and fontanels are obliterated. AVhether the primary fault has been an exag- 
gerated ossification, so that the brain cannot develop and is compressed, or 
the development of the brain is primarily arrested from some unknown cause, 
and the cranial arch consequently does not have its normal expansion, is 
uncertain. The following are cases of microcephalus as I have usually 
observed it : In August, 1878, an infant was brought into the Bureau for 
the Relief of the Out-door Poor with marked microcephalism. Its age was 
nineteen months, and the bone formation was so slow that only two teeth had 
appeared; the circumference of its head was fourteen and a half -inches; it 
had had repeated convulsions since the age of five months, and the mother 
stated that its head had been round and hard from its birth. The following 
case of microcephalus was brought to the Out-door Department in Jan., 1890 : 
Y , female, aged fourteen months, was born asphyxiated, and was resus- 
citated with difficulty. The cranial bones were firmly united at birth, so that 
the sutures and fontanels were obliterated, and the cranium was unyielding 
in every part on pressure. Clonic convulsions occurred at the age of one 
month, and have been frequent to the present time. The infant has internal 
strabismus, its mouth is open and drivelling, and it is evidently idiotic. 
Though fourteen months have elapsed since birth, the circumference of the 
head, measured over the occipital protuberance and the most prominent part 
of the forehead, is thirteen and a quarter inches, and the distance from one 
auditory meatus to the other, measured over the top of the head, seven 
inches. In microcephalus death, sooner or later, is the common result; life 
ends in convulsions and coma. 

Again, the brain of the child when undergoing development, with the 
cranial bones sufficiently yielding, may not only cease to grow, but may even 
diminish in size in consequence of protracted and exhausting diseases. Dim- 
inution in the size of the brain occurs especially after fevers and diarrhoeal 
affections of long standing and attended with much emaciation. The waste 
of the brain corresponds with the general loss of flesh. If the cranial 
sutures be not united, the occipital and sometimes the frontal bones are 
depressed according to the diminished size of the brain, and are overlaid by 
the parietal. In foundlings of two or three months this loss of brain-sub- 
stance is often very striking. In infants of this class who have died of 



HYPERTROPHY OF BRAIN. 523 

protracted diarrhoea it is not unusual to observe the occipital bone not 
only depressed, but extending one, two, or even three lines underneath 
the parietal. 

If the child with shrunken brain from protracted and exhausting disease 
be old enough to express its thoughts, it often seems foolish, talks but little, 
and perhaps says the same thing over and over again. In one case in my 
practice a little girl, having passed through a long course of typhus, persist- 
ently repeated during her convalescence with a silly smile the questions 
addressed to her. This peculiarity continued two or three weeks, although 
her appetite was good and her restoration to health rapid. In another case a 
little boy during convalescence was wont to laugh heartily at the appearance 
of the ordinary articles of furniture in the room. Both showed more impair- 
ment of mind during convalescence than in the midst of the fever. The 
friends of such children are in a state of great anxiety lest their minds be 
permanently enfeebled, but as the appetite and strength return the nutrition 
of the brain is re-established and the mind regains its former vigor. In cases 
of wasted brain with cranial bones united the deficiency is supplied by serous 
effusion, which is gradually absorbed as the health of the patient is re-estab- 
lished and the brain enlarges. This effusion occurs not only over the con- 
vexity of the brain, but also at its base, and sometimes in the ventricles. 
Dr. West states that in atrophy of the brain from protracted disease its tex- 
ture is firmer than usual. I have not noticed this in infants, but my atten- 
tion has not been directed particularly to this point. It is probable that 
there is some chans-e in the anatomical character of the brain aside from 

o 

mere waste. 

Partial atrophy of the brain sometimes also occurs from primary disease 
located in this organ ; the affected portion wastes, while the remainder of the 
brain has its normal development. 



CHAPTEE II. 

HYPERTROPHY OF BRAIN. 

In contrast with atrophy of the brain is the opposite state, or hypertro- 
phy. The size of this organ within the limits of health varies greatly in 
different individuals, but sometimes there is so great an increase in volume 
as properly to constitute a disease. Fortunately, hypertrophy of brain is 
rare in America. 

Pathological Anatomy. — The excess of growth which characterizes 
this disease has been ascertained to be confined to the white portion of the 
brain, and ordinarily to that part contained in the cerebral hemispheres. 
Hypertrophy of the brain is attended by induration, which exists in dif- 
ferent degrees in different cases. It is in some so slight as to be scarcely 
appreciable, while in others it is apparent at once by pressure with the finger 
or incision with the scalpel. Billiet and Barthez state that the induration in 
some cases resembles in degree and appearance that produced by the action 
of alcohol. The white substance of the cerebrum is not only resisting and 
elastic, but its color is unusually pale ; it presents even a brillant or polished 
appearance. At the same time, the gray substance is more or less faded, and 
its depth in the convolutions is less than in the normal state of the organ. 
Rokitansky says : " The cineritious matter is generally of a pale grayish-red 



524 HYPERTROPHY OF BRAIN. 

color. The medullary is always dazzling white and remarkably pale and 
anaemic." An unusual case is related by Burnet in which the gray substance 
in the corpora striata retained its usual color and was indurated like the white 
substance. In exceptional instances the cerebellum as well as cerebrum under- 
goes hypertrophy, becoming at the same time more or less indurated. In 
Burnet's case there was induration of the optic nerves. " The internal struc- 
ture," he says, " of the optic nerves, especially in their bulbs, had the polish, 
homogeneous appearance, elasticity, and almost the hardness of cartilage." 
Billiet and Barthez state that in two cases the spinal cord presented even 
more marked induration than the encephalon. Congestion is not a feature 
of hypertrophy. On the other hand, there is often less vascularity of the 
brain and its membranes than in the healthy state. If the cranial bones be 
completely ossified at the time when hypertrophy commences, and firmly 
united, enlargement of the brain is partially prevented. The convolutions 
are then thin, much flattened, the sulci more or less efl"aced, the membranes 
pale and dry, and the ventricles are small and nearly destitute of serum. At 
the autopsy of such a case, when the dura mater is incised the expansion of 
the brain prevents the proper refitting of the skullcap. Occasionally, hyper- 
trophy causes more or less absorption of the cranium, and perhaps the sutures 
already united are pressed apart. 

If hypertrophy commence in young infants with the fontanels and sutures 
still open, they usually remain open or are a long time in uniting. The inter- 
spaces continue, not only in consequence of the growth of the brain, which 
tends to separate the bones, but also in consequence of feeble ossification. 
The shape of the head arrests attention. Hypertrophy usually produces 
most enlargement between and above the ears, while the frontal portion of 
the head, though somewhat enlarged, is less developed. 

The direction of the eyes is not changed, as is common in congenital 
hydrocephalus. 

Rokitansky says (vol. iii. p. 285) : " With regard to the question to be 
decided by the theory and microscopic examination as to the nature of the 
added material upon which the increase of volume depends, I have formed the 
following opinion from repeated investigations : 
" 1. The disease is genuine hypertrophy ; 

"2. It consists, as such, not in an increase in the number of nerve-tubes 
in the brain from new ones being formed, nor in an increase in the dimensions 
of those which already exist, either as thickening of their sheaths or as aug- 
mentation of their contents, by either of which the nerve-tubes would become 
bulky ; but, 

" 3. It is an excessive accumulation of the intervening and connecting 
nucleated substance." 

It is now generally admitted that the views of Rokitansky are correct — 
that hypertrophy of the brain is due to an augmentation in the amount of 
connective tissue which lies between and unites the tubules. 

Causes. — Hypertrophy of the brain results from an error in the nutri- 
tive process which sometimes seems to be associated wHth the rachitic state 
or a condition analogous to rachitis. It is not common — is indeed rare — in 
this country, and is more common in countries like England where rachitis is 
more prevalent than with us. Billiet and Barthez consider frequent conges- 
tions of the brain as a common cause. The hypertrophy is most frequently 
met in hospitals for children and among the poor of cities whose systems are 
rendered cachectic by residence in damp and dark localities and by unwhole- 
some diet. In the deep valleys of Switzerland and in parts of South America 
and Asia hypertrophy of the brain is common, under the name of cretinism. 
It is associated with rachitis and stunted growth. The abnormal develop- 



SY2IFT0MS. 525 

ment which occurs in cretinism begins in infancy or early childhood, and the 
unfortunate subjects of it are short-lived. Cretinism has been attributed to 
a residence in localities wet and deprived in great measure of solar light, and 
to general disregard of the laws of health on the part of those affected, as 
well as their parents. 

The observations of different physicians also establish a connection between 
some cases of hypertrophy and the saturation of the system by lead. In what 
way lead-poisoning leads to hypertrophy is obscure, but the concurrent testi- 
mony of different observers is so strong that we cannot doubt that it does 
sometimes have that effect. But in a considerable proportion of cases, as in 
the one presently to be related, the cause is obscure. 

Symptoms. — The symptoms, as is the case with most organic diseases of 
the brain, vary considerably in different patients. Sometimes there is at first 
more or less depression or languor. If the child be old enough to speak, he 
may complain of pain in the abdomen or limbs, evidently neuralgic, or of 
headache. After a variable time vomiting succeeds, and finally convulsions, 
affecting the muscles of the face as well as extremities ; the convulsions are 
usually clonic, but sometimes, as regards at least the extremities, of a tonic 
character. The pupils may be contracted or dilated ; there is restlessness alter- 
nating with drowsiness, and finally coma succeeds. 

Hypertrophy may continue a considerable time before serious symptoms 
arise ; but when once developed these symptoms ordinarily continue with 
more or less severity till death. Death commonly results within a week 
after their commencement, but sometimes not till several weeks have elapsed. 
When death occurs at an early period in the disease, there is usually firm 
ossification and union of the cranial bones, and therefore but moderate 
enlaro-ement of the cranium. 

If hypertrophy commence at a period not far removed from birth, the 
bones of course yield more readily to the pressure and acute symptoms do 
not occur so soon. After a time, however, in all or nearly all cases, convul- 
sions supervene. These indicate the gravity of the disease and are prognos- 
tic of its fatal termination. 

In a patient observed by Burnet violent convulsions, followed by loss of 
consciousness, marked the commencement of acute symptoms. Five days 
subsequently the following symptoms were recorded : mobility of the eyes, 
without expression ; pupils contracted and directed upward ; divergent stra- 
bismus of the left eye ; the senses in their normal state, with the exception 
of sight; the limbs move by volition. For a month there was little change. 
Then occurred drowsiness and increased prostration, and five weeks later the 
child succumbed with the symptoms of double pneumonia. 

Such is the clinical history of h^'pertrophy. In cases of firm ossification 
of the cranial bones, and therefore no marked enlargement of the skull, the 
symptoms are similar to those which occur if the dimensions of the head be 
increased, but compression and death result sooner. 

The following case, in which the sutures were firmly united, I attended 
in 1864. The head was large, but not so large as to attract attention from 
its disproportion : 

Case. — A boy aged two years and two months had, when about one year old, 
intermittent fever, and since then his countenance was uniformly pallid and his 
flesh soft. Weaned at the usual time, he remained well till the 1st of January, 
1864. In the beginning of this month he was observed to be feverish for some 
days and his appetite poor. His health then gradually improved, and he was 
thought to be entirely well. 

On the 26th of February he was suddenly seized with convulsions, general at 
first, but most severe and continuing longest on the left side. The convul- 



526 HYPERTROPHY OF BRAIN. 

sions lasted a little more than three hours. He recovered fully his conscious- 
ness by the following day, but his appetite remained poor; he was no longer 
amused by his playthings and was very fretful. The surface was pallid ; bowels 
constipated ; pulse but little, perhaps not at all, accelerated. He continued in 
this state till the 6th of March, when he had another slight convulsive attack, 
and from this time he never fully recovered his consciousness. He was fretful 
if disturbed, his face generally pallid, while the pulse and respiration were not 
perceptibly altered. 

On the following day, the 7th, the left pupil was somewhat larger than the 
right, but both were sensitive to light, The difference in size continued till 
near the close of life. Although vision was imperfect, if not altogether lost, the 
sense of hearing was not impaired. 

When questioned, he uniformly answered, " No," with a drawling voice, evi- 
dently not understanding what he said. 

As the disease advanced the respiration became at times sighing, but the 
rhythm of the pulse was not materially altered. The temperature of the surface 
was changeable, sometimes cool, sometimes warm, and the congested spots or 
patches, so common in cerebral affections, were also observed at times on the 
face, ears, or forehead. Through most of his sickness he took drinks readily 
and the urine was freely discharged, probably from the iodide of potassium, 
which he took in one and a half grain doses every two hours. 

He became more and more drowsy, again had slight convulsive movements, 
and finally died, with much apparent suffering, on the 14th of March. The 
pulse became more accelerated during the last two or three days. On the day 
preceding his death the pupils were contracted and not affected by light. 

Sectio Cadav. — Body somewhat emaciated and eyes sunken ; occipito-frontal 
circumference of the head nineteen and a half inches; distance from one audi- 
tory meatus to the other over the vertex, thirteen and a half inches ; convolu- 
tions over the surface of the brain much flattened and compressed ; brain gen- 
erally deficient in blood ; medullary substance firm and of a pure white color ; 
meninges healthy ; no other abnormal appearances were observed ; weight of 
brain, forty -two ounces. Gowers says that enlargement of the brain occurs 
under three circumstances: ''(1) In very young children soon after birth; (2) 
Toward the end of the first year of life, in association with rickets; .... (3) 
In older children and adults, but of its nature little is known." He adds : 
" .... It is clear that the pathology of enlargement of the brain needs recon- 
sideration in the light of fresh investigation." ^ It seems to me that hypertrophy 
of the brain as observed in the cities, where most of the cases in this country 
apparently occur, is usually one of the manifestations of rachitis, and that the 
large head of the rachitic is commonly due to an increase in the neuroglia or 
connective tissue. 

Diagnosis. — The diagnosis of hypertrophy is not always easy. The symp- 
toms are, in the main, such as occur in other pathological states, especially con- 
genital hydrocephalus. There is most danger of mistaking the overgrowth 
for this disease. Hypertrophy has, indeed, often been treated for hydro- 
cephalus. There are, however, certain signs by which we may distinguish 
one from the other. In the ordinary form of congenital hydrocephalus, even 
when the amount of liquid is small, the orbital plates of the frontal bones 
are pressed in such a way that the axis of the eyes is changed so as to have 
a downward direction. The white of the eye can be seen between the iris 
and the upper eyelid. This gives a characteristic and striking expression to 
the face. The exception to this is in those rare cases in which the liquid is 
external to the brain. In hypertrophy this peculiar change in the axis of 
the eyes does not occur. Moreover, in hypertrophy there is not that uni- 
form expansion of the head which is observed in hydrocephalus, as has been 
stated above. There are, commonly, greater enlargement, more prominence 
of the anterior fontanel, and wider separation of the cranial bones in hydro- 
cephalus than in hypertrophy. But since in some cases of hydrocephalus 

^ Manual of Diseases of the Nervous Systeni, 1888. 



PROGS OSIS— TREATMENT. 5^7 

the sutures are united and the fontanels closed, and there is no change in 
the direction of the eyes, the reason of the diificulty in making a positive 
differential diagnosis between these two diseases in certain instances is 
apparent. 

Hypertrophy with consolidation of the cranial bones, and therefore little 
enlargement of the head, may be mistaken for meningitis. The history of 
the case and the means by which we diagnosticate the latter aifection, which 
will be described in their proper place, will usually enable the physician to 
make a correct diagnosis. 

Prognosis. — In forming an opinion as to the probable termination of the 
disease we must have regard to the age and general condition of the child, as 
well as to the degree of hypertrophy. If the disease commence at an early 
age, when the cranial bones are not firmly united, it is probable that there 
will be no compression of the brain, so as to endanger life, for a considerable 
period. We may then hope by proper measures to remove the constitutional 
state which gives rise to the hypertrophy, before the enlargement is such as 
to cause cerebral symptoms. If the bones have already united when the 
disease commences, even slight hypertrophy will produce symptoms, and a 
speedily fatal result is inevitable. Evidently, also, a child in a marked 
degree rachitic or scrofulous is much less likely to recover than one whose 
general health and constitution are less impaired. 

Treatment. — The treatment in hypertrophy should be directed mainly 
to the constitution. Measures calculated to improve the nutritive process 
are those most likely to check the abnormal growth of the brain. As the 
disease is one of perverted nutrition, and usually coexists with a vitiated or 
impoverished state of the blood, tonic and alterative remedies are required. 
The syrupus ferri iodidi is therefore useful, as it is both tonic and alterative. 
This may be given in doses of three or four drops, to a child one year old, 
three times daily. Cod-liver oil, with or without the iron, is beneficial in 
some cases. 

Growers, although he gives a good description of hypertrophy of the brain 
in his recent classical treatise on diseases of the nervous system, is silent as 
regards treatment. In my opinion, the hygienic and medicinal treatment 
should be the same as that for rachitis, to which the reader is referred. 



CHAPTER III. 

THROMBOSIS IN THE CEAXIAL SINUSES (PHLEBITIS). 

The formation of fibrinous coagula within a vein or sinus is designated 
thrombosis (thrombus, clot). Coagulation of fibrin in the cranial sinuses 
■occasionally occurs, constituting a very serious pathological state. This 
may result from local disease in the sinuses or in their vicinity or from 
disease external to the cranium. The immediate cause of thrombosis, 
whatever its location, is sufficient arrest of the circulation to allow the 
fibrin to coagulate. 

Tubercular and enlarged bronchial glands, compressing more or less the 
venae mnominata or the descending vena cava, sometimes give rise to throm- 
bosis in the cranial sinuses, the fibrin coagulating in consequence of retarda- 
tion in the current of blood. I have known thrombosis in the same situation 
also to result from clonic convulsions, occurring in connection with severe 



528 THROMBOSIS IN THE CRANIAL SINUSES. 

spasmodic cough in pertussis, since both the cough and convulsions retard 
the flow of blood in the veins and sinuses within the cranium. At the post- 
mortem examination of at least four such cases I found whitish clots in the 
lateral sinuses. 

Thrombosis in the cranial sinuses may also occur from inflammation, 
either in the walls of the sinuses or immediately exterior to them. This 
is the disease which writers have designated phlebitis of the cranial sinuses, 
and for a correct understanding of the morbid anatomy of which the profes- 
sion are indebted to Virchow. 

Anatomical Characters. — If a child die with the cranial sinuses and 
the veins of the brain and of the meninges in their normal state, the blood 
in these vessels is found at the autopsy dark but liquid, or there are small, 
dark, and soft clots in the larger sinuses. If there were congestion, but no 
coagulation, in these vessels in the last hours of life, the clots are more num- 
erous, larger, and longer, sometimes extending from the sinuses into the 
larger veins which empty into them, but they are still dark and soft, readily 
falling into pieces when handled. If, again, there have been that degree of 
congestion and stasis which has resulted in ante-mortem coagulation or in 
thrombosis, the clots are, in part at least, whitish and of a fibrinous or gelat- 
inous appearance ; they were formed while the red corpuscles were still 
carried along in the circulation. 

Most of the clots in thrombosis are free, while others are attached lightly 
to the internal surface of the sinus ; occasionally they are so large as to dis- 
tend the vessel. They extend also in many cases into the cerebral veins 
which connect with the sinuses, producing prominence and firmness, so as to 
resemble (Killiet and Barthez) an artificial injection. The clots do not pre- 
sent a uniform character. In parts of a sinus they consist of almost pure 
fibrin of a yellowish-white color ; in other portions they present a gelatinous 
appearance from the large number of white corpuscles, while other portions 
are more or less tinged from the presence of red corpuscles. The central 
part of the clot after a time, if the case be sufficiently protracted, softens 
and presents a puriform appearance. The substance, which is only disinte- 
grated fibrin, was supposed to be pus till the microscope revealed its true 
character. It is obvious that small clots forming within a sinus and having 
no attachment to its walls are liable to be carried by the current of blood 
into the general circulation, unless there be complete obstruction. Yirchow 
has also shown how a thrombus may extend, by gradual prolongation, nearer 
and nearer the heart, so that one commencing in a sinus may after a time 
reach into the jugular vein. Diff'erent observers, as M. Tonnele and also 
MM. Rilliet and Barthez, have traced the fibrinous masses as far as the cava. 
The latter writers relate the case of a girl four and a half years old in whom 
the sinuses on the left side, especially those nearest the petrous portion of 
the temporal bone, were completely tilled with clots of a yellowish-white 
color intermixed with central dark spots. Similar coagula were also found in 
the left jugular vein as far as the brachio-cephalic trunk. Whether the walls 
of the sinus undergo any change depends on the nature of th.e disease which 
causes the thrombosis. If it be phlebitis, the coats are thickened from infil- 
tration and injected and the internal coat has lost its polish. If it be some 
obstructive disease in the course of the circulation or a general cause, the 
coats of the vessels are unaltered, except that they may be stained by imbibi- 
tion of the coloring matter of the blood. In an infant who died of this dis- 
ease in the practice of Dr. West " the sinuses on the left side were healthy, 
but the blood was almost entirely coagulated. The posterior half of the lon- 
gitudinal sinus, the torcular, the left lateral, and the left occipital sinuses, 
were blocked up with fibrinous coagula, precisely such as one sees in inflamed 



CA USES. 529 

veins, and the clot extended into the internal jugular vein. The coats of the 
longitudinal and of the inner half of the lateral sinus were much thickened, 
and their lining membrane had lost its polish, was uneven, and presented a 
dirty appearance." 

The mode in which congestion and coagulation occur within a sinus in 
consequence of the pressure of a tumor upon this vessel, or upon a vein 
into which the blood from this sinus flows, is sufiiciently obvious. The mode 
of the production of thrombosis as a result of clonic convulsions or of the 
spasmodic cough of pertussis is also apparent. How it results from inflam- 
mation of the walls of a sinus — that is, from phlebitis — was not understood 
till explained by Virchow. 

The fibrinous coagula which fill the sinus are not an exudative product, 
as was formerly supposed. Inflammation (in most cases otitis, with caries of 
the petrous portion of the temporal bone) approaches a sinus. The inflam- 
matory products pressing against the walls of the sinus diminish its calibre 
at that point, and hence the retardation of blood and the coagulation. Or 
the walls of the sinus may be thickened by inflammatory infiltration, or even 
by the formation of little abscesses within the coats in consequence of the 
inflammation, so as to produce bulging inward, and the result, as regards the 
circulation, is the same. Whether, therefore, the inflammation occur without 
a sinus or within its walls, thrombosis equally results, provided that the 
diameter of the vessel is sufficiently narrowed by the presence and pressure 
of inflammatory products. 

There is no exudation on the internal surface of a sinus or vein when 
inflamed, as there is upon serous surfaces. " On the contrary,^ when the wall 
is inflamed the exuded matter (exsudatmasse) passes into the wall, which 
becomes thicker, cloudy, and subsequently begins to suppurate. Nay, even 
abscesses may form which cause the wall to bulge on both sides like a 
variolous pustule, without any coagulation of the blood ensuing in the cavity 
of the vessel. At other times, certainly, phlebitis, properly so called (and in 
like manner arteritis and endocarditis), is the cause of thrombosis, in conse- 
quence of the formation of inequalities, elevations, depressions, and even 
ulcerations, upon the inner wall, which favor the production of the thrombus. 
Still, whenever phlebitis, in the usual sense of the word, takes place, the 
alteration in the coat of the vessel is almost always a secondary one, and, 
indeed, occurs at a comparatively late period." 

This view of the pathology of thrombosis comports with facts observed 
at autopsies, and which cannot be explained according to the old theory of 
phlebitis — namely, smoothness of the internal surface of the sinus ; natural 
color of this sinus or simple staining from blood ; the non-attachment or 
slight attachment of the coagula, etc. 

Causes. — Some of these have been already stated at the commencement 
of this article. It is evident from what has been said that this disease may 
be produced by any cause which obstructs the return circulation from the 
head. I have already alluded to tumors which press upon the sinus or on 
the vein below the sinus, as a cause. Among the causes may be mentioned 
also abdominal tumors, narrowing of the chest from rachitis or caries of the 
vertebrae, and, finally, compression of the jugular vein by a peripharyngeal 
abscess. 

Sufficient allusion has already been made to inflammation of the internal 
ear as a not infrequent cause. Thrombosis is indeed one of the dangerous 
results of chronic otitis. Another cause is a reduced or cachectic state of 
system, apart from any local or obstructive disease. It is a noteworthy fact 
that a large proportion of those afi'ected with thrombosis, even when it is 

^ Cellular Pathology, translation, p. 236. 
34 



530 THROMBOSIS IN THE CRANIAL SINUSES. 

immediately due to obstructive disease, are cachectic. The explanation of 
this fact is not difficult. In reduced states of the system the action of the 
heart is feeble, and passive congestion of the vessels within the cranium is 
liable to occur. Passive congestion of the veins and sinuses in protracted 
diarrhoeal maladies, which is described in our remarks upon another disease, 
is an example in point. In this state of feeble circulation very slight 
obstructive disease may be sufficient to cause thrombosis. 

Symptoms. — The symptoms of this disease are often obscure. All of 
them may and do occur in other maladies of the encephalon. In cases 
related by M. Tonnele cerebral symptoms were well marked, such as faint- 
ness, dilatation of the pupils, strabismus, grinding of the teeth, convulsive 
movements. There may be an almost total absence of such symptoms as 
would direct attention to the state of the head. This is due to the sudden 
occurrence of death after the clots have formed in the sinuses. If the clots 
are large, death soon results in consequence of congestion of the brain and 
meninges, which is proportionate to the amount of obstruction. Extravasa- 
tions of blood and transudation of serum not infrequently accompany the 
congestion and hasten the result. 

Dr. West relates the case of a girl who had a mild attack of scarlet fever 
at the age of eight months, and did not fully recover her health. She con- 
tinued restless and feverish, and had two violent convulsions two weeks after 
the scarlatina. In the following months she had anasarca, and when she was 
nearly a year old another attack of convulsions occurred. Fluctuation was 
now observed in the abdomen, and in a few days a sero-purulent fluid began 
to escape from the umbilicus. When this discharge had continued eleven 
days, symptoms of a liquid in the right pleural cavity were suddenly devel- 
oped. She grew weak and emaciated, and finally was seized with extreme 
faintness, with which she died in forty-eight hours at the age of thirteen and 
a half months. 

At the post-mortem examination a large amount of pus was found in the 
abdominal and right pleural cavities. On the right side of the cranium the 
sinuses were filled with coagula and their coats seemed healthy. The left 
lateral and occipital sinuses, the torcular, and part of the longitudinal sinus, 
also contained coagula, which extended into the jugular vein. The walls of 
the longitudinal sinus and the internal part of the lateral sinus were thick- 
ened, and their inner surface had lost its polish and was uneven. There was 
congestion of the brain, with points of extra vasated blood. If, as is prob- 
able, the convulsions were due to some other cause, the only symptom which 
was clearly referable to the thrombosis was the sudden faintness. In the 
four cases of thrombosis occurring in pertussis already alluded to, in which 
I was enabled to ascertain by post-mortem examination the presence and 
extent of the clots, the symptonis, which were apparently due to the throm- 
bosis, were those of cerebral congestion. Among these symptoms stupor, 
and finally coma, were prominent. 

Diagnosis. — It is evident, from what has been said, that thrombosis of 
the cranial sinuses can rarely be diagnosticated with certainty. The pre- 
existence of otitis will sometimes lead us to suspect its presence, especially if 
the otitis have been accompanied by deep-seated pains. Symptoms of cere- 
bral congestion, serous effusion, or apoplexy, occurring in connection with 
otitis, protracted convulsions, or glandular or other tumors situated so as to 
compress the vessels which return blood from the brain, indicate thrombosis. 

Prognosis. — The prognosis in any case is obviously unfavorable. The 
cause is, ordinarily, permanent or not readily removed, so that the clots grad- 
ually increase. If the cause be a local obstructive disease, death is almost 
certain, since in nearly every instance the obstruction is of such a nature that 



CONGESTION OF THE BRAIN. 531 

it cannot be removed by medical or surgical treatment. It is possible that 
recovery may take place if the clots are few and small, and the cause of the 
thrombosis be mainly feebleness of circulation in consequence of a state of 
debility. We know that clots may liquefy, and their elements re-enter the 
circulation ; but such a result of thrombosis in a cranial sinus, if it ever 
occur, is rare. The thrombus by its presence serves as a point of attach- 
ment around which more fibrin coagulates, so that the obstruction gradually 
increases till death occurs. 

Treatment. — Thrombosis should be treated by cool applications to the 
head in order to diminish the congestion — by stimulants and sustaining meas- 
ures in case the systolic movement of the heart be feeble. Tonics, vegetable 
or ferruginous, are indicated if there be a cachectic state. 



CHAPTEK IV. 

CONGESTION OF THE BE A IN. 

Congestion of the brain is not peculiar to infancy and childhood, but is 
much more common in these periods of life than subsequently. This is due, 
in a great measure, to the fact that in the young the circulation is more read- 
ily disturbed by moral as well as physical causes than in the adult. 

Congestion of the brain is occasionally primary ; more frequently" it occurs 
as a concomitant or sequel of some other affection. Diseases, whether con- 
stitutional or local, which in the adult have no appreciable effect on the vas- 
cularity of the brain often cause in the child a decided increase of blood in 
this organ. 

Causes. — Cerebral congestion is of two kinds, active and passive. The 
former results from a cause which directly affects the brain and increases the 
flow of blood toward it, or from a cause operating primarily on the heart and 
increasing the frequency and force of its systolic movement ; the latter is due 
to some obstruction in the course of the circulation or to feeble propelling 
power on the part of the heart. 

Among the causes which most frequently produce active congestion of 
the brain in the child may be mentioned blows or falls on the head, excessive 
fatigue or excitement, heat, perhaps sometimes dentition, and also various 
inflammatory and febrile affections, especially in their first stages. 

Cerebral symptoms occurring in the course of an essential fever are no 
doubt often due, in a great measure, to the irritating effect on the brain of 
the specific principle, whatever it may be, circulating in the blood. Occur- 
ring in inflammatory diseases which are located elsewhere than within the 
cranium, they are often attributed to functional disturbance of the brain. The 
brain, it is said, sympathizes with the affected part through the system of nerves 
which unites them. But observations show that symptoms referable to the 
brain, arising in the commencement of the essential fevers and of the phleg- 
masiae, are in many instances preceded by, and are therefore doubtless in 
greater or less degree dependent on, hyperemia of this organ. 

Difficult as it is to ascertain the state of the brain in many diseases in 
which it is involved, we may determine whether or not there be congestion 
in the young child by observing the anterior fontanel. If it be elevated and 
tense in an acute disease, hyperasmia is indicated. Now, it is often unusually 
prominent in fevers and inflammations, especially in their first stages, when 



532 CONGESTION OF THE BRAIN. 

cerebral symptoms are present. Its elevation, under such circumstances, is 
obviously coincident with cerebral congestion. 

The acute inflammations which are most likely to be attended by cerebral 
congestion are those of the mucous surfaces and pneumonia. Severe coryza, 
tracheo-bronchitis. entero-colitis, and colitis, commencing suddenly with great 
febrile excitement, are frequently accompanied in their initial stage by active 
congestion of the cerebral vessels. Cases like the following, which I find in 
my note-book, are not infrequent : An infant four months old had been sick 
about two days with coryza and bronchitis when I was called to see it ; the 
pulse numbered 156, respiration 64; it nursed and was somewhat restless; 
cough frequent and dry ; bowels moderately relaxed. The mucous mem- 
brane of the fauces was injected, and coarse mucous rales were present in 
the chest. The anterior fontanel rose above the level of the cranium and 
pulsated forcibly. Soon after convulsions occurred, which were relieved by 
appropriate measures, and on the following day the fontanel had subsided. 
The patient gradually recovered without any untoward symptom. 

Cerebral congestion and convulsions often mark the initial stage of active 
intestinal phlegmasiae. This is especially true of dysentery. The little 
patient, perhaps from the very inception of the colitis, is drowsy ; its surface 
hot ; pulse full and rapid. There is sudden and momentary starting or twitch- 
ing of the limbs. The anterior fontanel, if still open, is elevated, and it is not 
till the lapse of several hours that the cause of these symptoms is apparent 
from the occurrence of bloody stools. 

The causes of passive congestion of the brain are very different from those 
of the active form. A common cause is obstruction in a sinus or vein by a 
fibrinous concretion or by a tumor or abscess external to it. 

I have occasionally met cases in which this form of cerebral congestion 
appeared to be plainly referable to obstruction to the return of blood from 
the brain by the pressure of bronchial glands, enlarged by hyperplasia in 
tubercular disease, these bodies diminishing by external pressure the calibre 
of the venae innominatae or the descending vena cava. Rilliet and Barthez 
have called attention to such cases in the clinical history of tuberculosis. 
The following case may be cited as an example ; it occurred in the infants' 
service of Charity Hospital in this city in April, 1866 : 

An infant about one year old, affected with tuberculosis, both bronchial 
and pulmonary, was observed during the ten days preceding its death to bore 
the pillow with its head almost constantly, so as to wear the hair from the 
occiput. The movement of the head was the only prominent cerebral symp- 
tom. Nothing abnormal was noticed in the appearance of the eyes, nor was 
the stomach irritable. A spasmodic cough and progressive emaciation attracted 
attention, but these were referable to the tubercular disease. At the autopsy 
we found the cerebral sinuses, veins, and capillaries greatly congested. On 
tracing the veins which return blood from the brain, an inflamed and enlarged 
bronchial gland was discovered in the angle formed by the convergence of 
the right and left venae innominatae. This gland, which contained but a 
single point of cheesy degeneration, had attained such a volume by prolifera- 
tion of its cells that it pressed upon both vessels, so that it had obviously 
retarded the circulation in each and given rise to cerebral congestion. 

Passive congestion often occurs in the infant at birth, either from tedious- 
ness of the labor or delay in the expulsion of the body after the birth of the 
head. If it be simple congestion, and not congestion with hemorrhage, it 
soon passes off. Passive congestion of the brain also occurs in severe 
paroxysms of whooping cough, in which return of blood from this organ 
is temporarily retarded. All are familiar with the congestion which occurs 
in parts external to the cranium from the severity of the cough, producing 



SY3IPT0MS—PR0G.X0SIS. 533 

epistaxis, extravasations under the conjunctiva, etc. The extra-cranial con- 
gestion obviously indicates the presence and degree of congestion within the 
cranium. 

Those who practise in malarious regions sometimes meet cases of dan- 
gerous passive congestion of the brain, the result of malaria, occurring 
especially in the cold state of intermittent fever. In these cases the surface 
is pallid, its temperature reduced, and the pulse feeble. The blood, leaving 
the peripheral vessels, collects in undue quantity in the internal organs, pro- 
ducing congestion of the brain as well as of the thoracic and abdominal 
viscera. In the child with malarial disease, in whom there is less vigor of 
constitution than in the adult, death sometimes results from this passive 
congestion. Two such cases have occurred in my practice, although in this 
latitude the malarial maladies are mild in comparison with the type which 
they present in many parts of the United States. 

Symptoms. — The symptoms of active congestion of the brain are stupor, 
great heat of head, throbbing of carotids, restlessness when aroused, twitching 
of the limbs, and perhaps convulsions. There is also sometimes intolerance 
of light, and the anterior fontanel, if open, pulsates strongly. In passive 
congestion many of the symptoms are the same as in the active form. 
Stupor, twitching of the limbs, and fretfulness or irritability when the patient 
is disturbed are common, ordinarily without increase of temperature ; the 
surface may indeed be cool and the face is not flushed nor the eyes injected. 
The strong pulsation and elevation of the anterior fontanel, so conspicuous in 
active congestion, are — the former always, the latter often — lacking. In both 
acute and passive cerebral congestion constipation is a common symptom. 

In many cases the symptoms of congestion of the brain are associated 
with others which proceed directly from the cause of the congestion, but it is 
not difficult, unless in exceptional instances, to determine which are due to 
the congestion and which to the antecedent and coexisting pathological state. 

Anatomical Characters. — In active congestion there is an excess of 
arterial blood in the brain and its membranes. The arteries, to their minutest 
branches, are seen to be full, presenting the bright hue of oxygenated blood. 
In passive congestion the sinuses and veins are distended. The pia mater, 
choroid plexus, and the vessels of the brain have a darker appearance than in 
active congestion. In both forms of congestion, unless they quickly abate, 
other anatomical changes soon occur. If there be great distension of the 
capillaries, these vessels are liable to give way, and we find here and there 
little patches of extravasated blood. In other cases the over-distension is 
relieved by the transudation of the serous portion of the blood through the 
coats of the vessels. The cephalo-rachidian fluid is then found in excess 
external to the brain and in the ventricles. 

Prognosis. — The duration and the result of congestion of the brain 
depend, in great measure, on the nature of the cause. If the cause be 
trivial, as mental excitement, fatigue, exposure to heat, there is usually 
prompt relief if the condition of the patient be understood and properly 
treated. If the cause be general or constitutional, as one of the essential 
fevers or whooping cough, or if it be local, but its seat external to the 
cranium, the prognosis, so far as the congestion is concerned, is not unfavor- 
able if there be a timely and judicious use of remedies. The most unfavor- 
able cases are those, in which the cause is seated in the encephalon and those 
in which there is some obstructive disease in the course of the circulation. 
Congestion occurring from a structural change within the cranium is. from 
the nature of the cause, without remedy and ordinarily fatal. Obstructive 
diseases of the circulatory system, wherever located, being for the most part 
permanent, give rise, as a rule, to incurable congestion. 



534 INTRACRANIAL HEMORRHAGE. 

Congestion of the brain, if it be not relieved in a few hours, becomes less 
and less amenable to treatment. It soon passes beyond the resources of our 
art and ends in coma ; it is seldom protracted beyond a few days. Extrava- 
sations of blood, common in active congestion, and serous effusion, common in 
the passive form, diminish the chances of a favorable result. 

Treatment. — The indication for treatment in active congestion is plain. 
Measures should be employed which produce derivation from the brain. 
Unless there be an asthenic primary affection, in the course of which the 
congestion is developed, active purgation is required. A saline purgative is 
ordinarily preferable. If the stomach be irritable there is no better purga- 
tive than calomel. In all cases of active congestion, whatever the cause, the 
bowels should be kept open. It is often better not to wait for the tardy action 
of a cathartic, but to give at once an enema of soap and water or salt and 
water. External derivative agents are also indicated. A warm mustard foot- 
bath, sinapisms to the back of the neck or chest and to the feet, and cold 
applications to the head, are measures which should never be neglected. In 
many cases those medicines are useful which reduce the contractile power of 
the heart, as antipyrine, antifebrin, or phenacetin. 

This treatment, if employed early, will relieve the congestion in a large 
proportion of cases ; but if there be no improvement, if the child be robust, 
and if the primary affection be such as does not contraindicate loss of blood, 
leeches should be applied to the temples or some part of the head. If after 
the lapse of some hours cerebral symptoms continue, apoplexy or serous 
effusion has probably occurred. Congestion is then no longer the prominent 
lesion, and it is proper to designate the disease by another name. 

The treatment appropriate for passive congestion is somewhat different ; 
cold applications to the head and those of a derivative nature to the extremi- 
ties are useful. As this form of the disease is not primary, but is dependent 
on some antecedent pathological state, it is evident that it can only be treated 
successfully by removing or obviating the cause as far as possible. But the 
nature of the various obstructions to the intracranial circulation is such that 
our ability to accomplish this end is very limited. 

If the cause be constitutional, or if it be some disease in the neck or 
chest, it may sometimes be partially or even wholly removed, but if seated 
within the cranium it is beyond our control. In general, it may be said that 
depletion is not required or tolerated in passive congestion, and stimulants 
are often needed. 



CHAPTER V. 

INTRACRANIAL HEMORRHAGE (MENINGEAL HEMORRHAGE, 
CEREBRAL HEMORRHAGE). 

Hemorrhage within the cranium is not very infrequent in infancy -and 
childhood, and there is no part of the encephalon, whether the meninges or 
brain, in which it does not sometimes occur. If the blood be extravasated 
upon the surface of the brain or between the meninges, the disease is desig- 
nated by writers meningeal apoplexy ; if in the substance of the brain, 
cerebral apoplexy. Extravasation may also occur in one of the lateral 
ventricles. This may, for convenience, be described as a form of meningeal 
apoplexy. 



CAUSES— ANATOMICAL CHARACTERS. 535 

Causes. — Apoplexy is usually (there is an exception) preceded by con- 
gestion." If the congestion increase to a certain degree, the distended capil- 
laries give way and extravasation of blood results. Therefore the causes of 
congestion which have been enumerated in the preceding chapter are, in great 
measure, those of apoplexy. Recent microscopic examinations have demon- 
strated that the corpuscular elements of the blood may escape from capillaries 
without rupture. While, therefore, it is probable that intracranial hemorrhage 
in early life commonly occurs from rupture, its occasional occurrence through 
the walls of the capillaries must be admitted. 

Intracranial hemorrhage is not infrequent in the new-born. It results in 
them from tediousness of the birth and severity of the labor-pains. At first 
there is extreme congestion of the meningeal and cerebral vessels, correspond- 
ing with that of the scalp and face. This congestion, continuing, soon ends 
in extravasation of blood. In some of these cases forceps have been used to 
effect the delivery, but it is doubtful whether the use of instruments materially 
increases the congestion or the amount of extravasation. Certainly, in a 
large proportion of intracranial as well as supracranial hemorrhages of the 
new-born instruments have not been used. An additional cause of the 
hemorrhage is, in some instances, the use of ergot, which, by producing 
strong and continuous pains, interrupts the placental circulation and increases 
the congestion of the foetal veins and capillaries. 

In infants a few days old intracranial hemorrhage may result from that 
rapid and fatal disease, tetanus infantum. The hemorrhage is preceded by 
intense passive congestion, which the tetanic rigidity and spasms produce by 
obstructing respiration and circulation. Few cases of tetanus infantum occur 
without more or less extravasation of blood, either meningeal or cerebral. 
Another cause of this disease is obstruction in the vessels which return the 
blood from the brain. The various structural changes which produce this 
obstruction in different cases have been sufficiently described in our remarks 
on cerebral congestion and thrombosis. 

The congestion which precedes hemorrhage, when occurring under the 
conditions described above, is passive. 

Among the causes which produce hemorrhage through the intermediate 
state of active congestion may be mentioned great mental excitement, of 
which M. Legendre relates a case, and lengthened exposure to the sun's rays, 
an example of which Rilliet and Barthez have seen. It is also said that 
compression of the aorta by an enlarged liver or an abdominal tumor has 
sometimes produced meningeal or cerebral hemorrhage by causing an increased 
afflux of blood to the head. A very important cause to which I have not 
alluded is that general state of the circulatory system which is designated 
by the term purpura hfemorrhagica. This sometimes results from the anti- 
hygienic conditions in which the child is placed. In other instances it results 
from some antecedent disease, protracted and debilitating, which has pro- 
duced a profound alteration in the state of the blood and the vessels. The 
capillaries become less firm and elastic and easily give way, so that in such 
patients ecchymotic points are ordinarily found in different parts of the sys- 
tem. The diseases which occasionally end in this hemorrhagic diathesis are 
numerous. I have known it to occur after measles, scarlet fever, and small- 
pox. It is also an occasional sequel of chronic diarrhoea or intermittent and 
typhoid fevers, and of rachitis. 

Anatomical Characters.— Hemorrhage in or upon the brain in infancy 
and childhood differs in important particulars from that occurring in adult life. 
In the adult, and more so as life advances, the arteries become less detensible 
and more brittle, so that when hemorrhage occurs it is usually from one of 
these vessels. In early life, on the other hand, the blood does not ordinarily 



536 INTRACRANIAL HEMORRHAGE. 

escape from an artery, but, as has been stated, from the capillaries. The 
extravasation is not, therefore, so rapid and violent, and is not attended by 
such laceration and injury of surrounding parts in infancy, and childhood as 
at a subsequent age. In the adult the hemorrhage commonly occurs in the 
substance of the brain. The flow of blood from the ruptured artery separates 
the brain-substance, producing a cavity in which a clot forms. This consti- 
tutes the usual form of apoplexy in the adult. In the first years of life, on 
the contrary, the extravasation is commonly from the meninges, and the 
symptoms to which the effused fluid gives rise are for the most part due to 
its mechanical effect. Cases of hemorrhage in the substance of the brain 
constitute a small minority, unless during the days immediately succeeding 
birth. In early life, therefore, on account of its greater frequency, menin- 
geal hemorrhage is a disease of more importance than cerebral, and its ana- 
tomical character should be carefully studied. 

In Meningeal Hemorrhage the extravasation may be between the 
cranium and dura mater, upon the visceral layer of the arachnoid, in the 
meshes of the pia mater, or in a lateral ventricle from rupture of the capil- 
laries in the choroid plexus. Much the most common seat is external to the 
pia mater in the so-called cavity of the arachnoid ; the blood escaping in this 
situation spreads uniformly in all directions. It soon separates into two por- 
tions, the solid and liquid. The solid portion, or the clot, is free or but 
slightly attached to the adjacent membrane. The meninges in the vicinity 
of the extravasated blood preserve their normal appearance or are but slightly 
injected ; the clot gradually becomes extended on all sides, so as to form a 
lamina at the seat of the extravasation, thinner at its circumference than 
centre, and at first of a dark-red color. The color gradually fades, and the 
lamina, becoming smooth and polished and at the same time more and more 
attenuated, finally resembles the arachnoid in appearance. Its diameter 
varies in different cases from a few lines to two or three or more inches. 
M. Tonnele relates two observations in which the adventitious membrane 
extended over the superior surface of both hemispheres, and in one of them 
also over the falx cerebri. 

The extravasation may occur at any part of the surface of the brain, but 
its usual seat is the vertex. The next most frequent locality is the base of 
the brain. The subsequent history of the delicate membrane into which the 
clot is gradually transformed is interesting. It often extends so as to cover 
more space than was occupied by the extravasated blood, and its edges are 
then scarcely distinguishable, in consequence of their extreme tenuity and 
their close resemblance to the arachnoid. The attachments of this mem- 
brane, so far as it forms any, are usually to the parietal surface of the arach- 
noid. Sometimes a portion of the membrane is attached, while the rest lies 
free, bathed on either side by the liquid portion of the blood which still 
remains from the extravasation. According to M. Legendre, in the most 
favorable cases the serum is absorbed, and the membrane which has resulted 
from the clot, and which I have described, becomes intimately adherent to 
the internal surface of the dura mater. It forms an integral part of this 
membrane, and there only remain a little thickening and increased opacity, 
indicating the seat of the extravasation. The health is fully re-established. 

But the result in other cases is as follows : The serum is not absorbed, 
and the newly-formed membrane, uniting at points with the inner surface of 
the dura mater or its arachnoidal covering, encloses the fluid so as to produce 
a circumscribed hydrocephalus. 

Sometimes there is only one cyst ; in other instances the membrane, 
especially if large, unites in such a way as to give rise to more cysts than 
one. The size of the cyst varies according to the quantity of fluid, which 



ANATOMICAL CHARACTERS. 537 

may be only a few drachms or several ounces. Rilliet and Barthez report a 
case in which there was a pint of fluid lying over each hemisphere, there 
being two cysts. If the cranial bones are not united, so that they yield to 
the pressure, the size of the cranium is increased, and if the extravasation 
be confined to one side, an inequality results and the symmetry of the head 
is destroyed. The fluid which causes the enlargement of the head in such 
cases is in part the serum of the extravasated blood and in part a subsequent 
secretion. 

Various writers relate cases of ventricular hemorrhage. Yalleix met it 
in an infant that died at the age of two days. In the Edinhurgli Journal 
of Medicine and Surgery^ October, 1831, an interesting case is related. A 
boy nine years old died of hemorrhage in both ventricles, and also at the 
base of the brain and in the spinal canal. In the Nursery and Child's Hos- 
pital of this city the post-mortem examination was made of an infant who 
died at the age of one month. In the posterior cornu of the left lateral 
ventricle were two clots, elongated and black, one larger than the other. In 
the corresponding cornu on the opposite side was a smaller clot. A similar 
post-mortem appearance was observed at the autopsy of a young infant 
that died in Charity Hospital. A dark crescentic clot lay in each pos- 
terior cornu. The clot, if remaining a long time, undergoes degeneration. 
In the case of an adult in which a year had elapsed after the extravasation I 
found it to contain crystals of cholesterin and carbonate of lime. 

Cerebral Hemorrhag'e, or hemorrhage in the substance of the brain, 
may occur at any time in infancy and childhood. The blood is sometimes 
extravasated in points here and there over the entire organ or a part of the 
organ ; in other cases it is extravasated in one or perhaps two cavities, as in 
the ordinary form of apoplexy in the adult. In the first form of cerebral 
hemorrhage, or that in which the blood escapes from numerous points through 
the brain, there is evidently little laceration or injury of the organ. The 
brain-substance surrounding the hemorrhagic points sometimes preserves the 
usual appearance. It is white and firm. In other cases it presents a reddish 
or yellowish appearance, and is softened to the depth of a line or two. If 
the hemorrhage occur in a cavity, as in apoplexy of adults, the nerve-fibres 
are evidently torn and separated and there is more or less compression of the 
surrounding brain-substance. Unless the disease be of long standing, the 
cavity contains a dark and soft clot bathed with serum which has a reddish 
or a yellowish-red appearance. The brain in the im.mediate vicinity of the 
cavity is sometimes softened. Rilliet and Barthez state that they have seen 
8 cases of cerebral hemorrhage of the capillary form ; 10 cases in which the 
hemorrhage was in cavities ; and in 2 of the 18 both forms were present. In 
5 of those in which the form was capillary the disease was limited to portions 
of the brain, while in the remaining 3 the hemorrhagic points were found in 
nearly every part of the brain. 

Apoplectic cavities are seldom seen in the cerebellum, and, whether the 
hemorrhage be capillary or in a cavity, there is in most cases, as previously 
stated, more or less congestion of the vessels of the brain. 

The proportion of cases of cerebral to other forms of hemorrhage is 
believed by some to be greater in the new-born than at any other period of 
life. Yalleix relates 4 cases of intracranial hemorrhage occurring at this age, 
2 of which were cerebral, 1 ventricular, and in the other the extravasation 
was in the cavity of the arachnoid. Mignot has published 8 cases occurring 
in the new-born, in 2 of which the hemorrhage was in cavities in the cere- 
brum ; in 3, in the lateral ventricles ; and in 3, external to the brain. If the 
same proportion be observed in other statistics, 1 in 3 of the cases of intra- 
cranial hemorrhage occurring in the new-born is cerebral. 



538 INTRACRANIAL HEMORRHAGE. 

Symptoms. — The symptoms in intracranial hemorrhage are not uniform ; 
they vary according to the seat as well as the quantity of the effused blood. 
In some cases the extravasation occurs without such symptoms as would 
direct attention to the brain. When the hemorrhage occurs at the time of 
birth in consequence of strong and long-continued labor-pains, the infant is 
often born apparently dead. This is due partly to the hemorrhage, partly to 
the great congestion of the brain which precedes and accompanies the hemor- 
rhage. Resuscitation is gradual and difficult. The infant's features are livid 
and perhaps swollen ; its respiration is gasping, and both pulse and respira- 
tion are slow. Its cry is feeble, with but slight movement of the facial 
muscles, and the lungs are but partially inflated ; the eyelids are closed and 
the limbs almost motionless. By artificial respiration and by friction the 
pulse and breathing may be rendered more frequent, but the latter remains 
irregular and gasping. Finally, the limbs grow cold, the surface, from a state 
of lividity, becomes pallid, and death occurs in profound coma. M. Cruveil- 
hier made many observations at the Maternite in reference to the death of 
new-born infants, and he believes that one-third of those who die in birth at 
the full period die of apoplexy. I have made post-mortem examinations in a 
few cases when death had occurred from this cause, and in all the hemorrhage 
was meningeal. One of these was born on the 30th of December, 1864. 
The birth was delayed by unusual projection of the promontory of the 
sacrum, so that finally the application of forceps was necessary. The infant 
was apparently stillborn, but by persistent efl'orts on the part of the physician 
who assisted it was resuscitated so as to live several hours, though with con- 
stant embarrassment of respiration and with lividity. At the autopsy a large 
extravasation of blood was found in the cavity of the arachnoid over a con- 
siderable part of the convexity of the brain, and the substance of the brain 
was deeply congested. 

Apoplexy in the new-born does not always terminate fatally, or, when 
fatal, in the sudden manner which I have described. Yalleix relates the 
case of an infant who died of pneumonia at the age of three and a half 
months. Its birth had been protracted and difficult, but was completed with- 
out the use of instruments. It had had during its entire life paralysis of the 
right side. At the autopsy a clot was found near the base of the right 
thalamus opticus, evidently existing from birth. Around the clot the brain 
was softened to the depth of some lines and was of a bluish-red color. A 
very similar case is related by M. Yernois. An infant lived forty-nine days 
with paralysis of the left side, and died of pneumonia. At the autopsy a 
hemorrhagic excavation in process of cicatrization was found behind the right 
corpus striatum and the thalamus opticus. 

Intracranial hemorrhage occurring from accidents of birth is generally 
attended by marked symptoms, such as have been described. But when it 
occurs subsequently to birth, whether in infancy or childhood, the symptoms 
vary greatly in diff'erent cases and are generally obscure. I will briefly state 
the symptoms which have been observed in both the cerebral and meningeal 
forms of this disease. First, the cerebral. Sedillot relates the case of a child 
seven and a half years old whose bare head had been exposed several hours 
to the sun's rays. Suddenly, after a paroxysm of anger, it was seized with 
great pain, corresponding with the posterior and inferior fossae of the cranium. 
It uttered piercing cries and died in a quarter of an hour. A clot was found 
in the right lobe of the cerebellum. Richard Quinn (Rilliet and Barthez) 
gives the history of a boy nine years old who in playing with a hoop sud- 
denly stopped, carried his hands to his head, and fell backward unconscious. 
Three or four hours afterward, when examined, he was found pale, surface 
cool, respiration slow and at times stertorous, pulse 50 to 60 per minute; 



SYMPTOMS. 539 

the left arm was flexed, the left leg paralyzed ; the right leg and arm con- 
vulsed ; right pupil strongly dilated, the left contracted. He died seven 
hours after the commencement of the attack, and a large clot was found 
in the centrum ovale on the right side. 

Rilliet and Barthez relate the following case from Campbell : A boy with 
good previous health was suddenly seized about 7 A. M. with repeated vomiting, 
followed in an hour and a half by violent convulsions ; he rolled his eyes and 
uttered inarticulate cries ; pulse frequent and hard ; pupils contracted ; trunk 
and lower extremities cool. In the afternoon he presented symptoms of com- 
pression of the brain, such as dilatation of the pupils, frequent and feeble 
pulse. Death occurred in the evening, and a hemorrhagic cavity was found 
occupying the right middle lobe of the cerebrum. Guibert relates a case of 
extravasation in the superior part of the right hemisphere of the brain in a 
boy fourteen years old. The principal symptoms were feebleness of the 
limbs, inability to walk, cephalalgia, involuntary evacuations, fever, grinding 
the teeth, rigors severe and prolonged, lividity, loss of intellectual facul- 
ties, dilatation of the pupils, insensibility to light, stertorous respiration. 
Death occurred in about an hour, 

Rilliet and Barthez narrate the history of a girl two years old who, after 
an attack of measles, was taken with convulsions accompanied with fever and 
prostration. The convulsive movements affected especially the eyes and upper 
extremities ; the right leg was immovable ; the left pupil dilated. These 
symptoms resulted from hemorrhage in the corpus striatum and opticus 
thalamus. The same authors relate also the case of a girl seven years old 
who died with a large apoplectic cavity in the left thalamus opticus. The 
symptoms were headache, convulsive movements, loss of consciousness, delir- 
ium, vomiting and constipation, and convergent strabismus. These symp- 
toms nearly disappeared, but in a few days the headache returned, with 
strabismus and a slight drawing of the face toward the left ; on the twenty- 
seventh day convulsive movements of the right eye were observed, with 
paralysis of the arm. Finally, contraction of the arms occurred, with accele- 
ration of pulse, irregular breathing, dilated pupils, paralysis, and retraction 
of the head, followed by death on the forty-eighth day. 

These cases, and those from Valleix and Vernois which have been related 
in our remarks on hemorrhage of the new-born, are sufficient to show the 
character of the symptoms in that form of cerebral hemorrhage in which the 
extra vasated blood forms a cavity in the interior of the brain. 

If the amount of extravasation be large and the substance of the brain 
be much lacerated and compressed, death may occur almost immediately, and 
therefore without symptoms, or before it is possible to determine whether 
or not symptoms are present. If the disease be not so speedily fatal the 
symptoms, as appears from the above cases, are headache, confusion of 
thought, or even insensibility ; cries, sometimes piercing ; cold extremities, 
pallor, slow and perhaps stertorous respiration ; convulsive movements fol- 
lowed by paralysis, or convulsions affecting one or more limbs, with paralysis 
of others ; pupils contracted or dilated, sometimes one contracted and the 
other dilated ; strabismus, rolling of eyes, vomiting. 

These symptoms have all been observed in different cases, but they are 
not all present in any one case. Those which are generally present, and on 
which we mainly rely for diagnosis, are headache, convulsive movements, 
paralysis, confusion of thought, irregularity in the pupils, and strabismus. 

In the capillary form of cerebral hemorrhage there is usually some 
complication, so that it is not easy to determine how far symptoms are due 
to the hemorrhage and how far to the coexisting pathological state. 

There are, indeed, but few published observations of hemorrhage in the 



540 INTRACRANIAL HEMORRHAGE. 

substance of the brain unaccompanied with meningeal hemorrhage, hemor- 
rhage into a ventricle, or some other distinct disease ; but so far as I have 
been able to ascertain the symptoms referable to this form of extravasation, 
they are as follows : The child is drowsy ; fretful when disturbed ; it per- 
haps moans. There are sometimes slight convulsive movements and partial 
paralysis. If there be considerable extravasation, the respiration is irregular 
and sighing. Death occurs in coma, occasionally preceded by convulsions. 
Taupin relates the case of a child nine years old who died with this form of 
hemorrhage, accompanied by softening of the brain. The disease began at 
night with delirium, agitation, and piercing cries. In the morning the patient 
lay in bed, drowsy, not complaining of pain and not replying to questions ; 
pupils dilated and insensible to light ; left eye half open during sleep and its 
axis changed ; eyebrows contracted ; face pale ; mouth open ; had no convul- 
sions, but transient stiffening of the limbs, during which the thumbs were 
firmly compressed by the fingers ; senses unimpaired, but the face drawn to 
the right ; deglutition difficult ; pulse small, irregular, and feeble ; respira- 
tion 32, sighing. In the evening he had rigidity of the limbs and back, and 
finally was taken with general convulsions, in which he died at eleven o'clock. 
The hemorrhagic points in this case were numerous. A boy five years old, 
whose case is described by Rilliet and Barthez, died of this disease, pneu- 
monia, and white softening of the intestine. During the last five days there 
were cerebral symptoms, the chief of which were drowsiness, fretfulness 
when disturbed, and moaning without apparent cause. Another child, whose 
case is described by Rilliet and Barthez, died at the age of four years with 
cerebral capillary hemorrhage, accompanied by yellow softening. Six months 
before death he had general convulsions, followed by spasmodic movements 
of the left side. These subsided, but the left side remained feeble. 

In Meningeal Hemorrhage there are often convulsions, general or par- 
tial — in some patients tonic, in others clonic. When partial, the convulsive 
movements may only occur in the muscles of the face and eyes. With the 
spasmodic muscular action is a degree of drowsiness with irritability. Paral- 
ysis, so common in the apoplexy of the adult, and not infrequent, as we 
have seen, in the cerebral form in early life, is sometimes, but not ordinarily, 
present in meningeal hemorrhage." Instead of paralysis, there are vomiting, 
some febrile action, thirst, and loss of appetite. The symptoms are different, 
however, according to the exact seat of the hemorrhagic extravasation and 
the duration of the disease. If the extravasation end in the formation of a 
cyst, the symptoms are those of hydrocephalus. The following condensed 
history of cases which I have selected as typical will give us a clearer idea 
of the histor}'^ and course of the various forms of meningeal hemorrhage 
than can be imparted by a narration of symptoms. 

M. Tonnele relates the cas^ of a child who was taken with faintness and 
convulsive movements. On the following day the trunk and inferior extrem- 
ities became rigid ; deglutition was painful ; the pupils were largely dilated, 
immovable ; face pale ; pulse feeble and intermittent. Death occurred the 
same day. The dura mater was distended. A layer of coagulated blood of 
great thickness extended over the convexity of each hemisphere. The veins 
ramifying into the superior portion of the cerebrum were distended with 
coagulated blood. The hemorrhage was in the meshes of the pia mater. 
Drs. Lombard and Panchard of Geneva relate a somewhat similar case. A 
child thirteen months old was convalescing from inflammation of the bron- 
chial and intestinal mucous surfaces when it was seized with general convul- 
sions ; the mouth and eyes were open and the eyes directed upward ; pupils 
contracted; pulse frequent and irregular. The convulsions abated some- 
what, but soon reappeared with violence. The patient became insensible, 



DIAGNOSIS— TBEATMENT. 541 

and died nineteen hours after the commencement of cerebral symptoms. 
The extravasated blood covered the upper surface of both hemispheres. 
From the above cases we see the symptoms and the course of meningeal 
hemorrhage when the extravasation is so large that death speedily results. 
In protracted cases of meningeal hemorrhage there is either a gradual disap- 
pearance of symptoms and return to health, or, circumscribed hydrocephalus 
occurring, the symptoms of that disease arise. 

Diagnosis. — It is evident, from what has been stated, that the diagnosis 
of intracranial hemorrhage is attended with unusual difficulty, since the 
symptoms of this disease occur also in other and distinct pathological states. 
The history of the case, and especially the character of the cause, if ascer- 
tained, will aid in diagnosis. If there has been an obvious determination 
of blood to the brain or some known obstruction to the return of blood from 
that organ, the persistence of cerebral symptoms would justify us in con- 
cluding that either serous or sanguineous effusion had supervened on a state 
of congestion. The points of differential diagnosis between apoplexy and 
meningitis are the sudden and full development of symptoms in one case, 
the gradual commencement and gradual increase of symptoms in the other ; 
differences also of S3'raptoms in certain respects ; for example, as regards 
fever, constipation, etc. 

There is one symptom in cerebral hemorrhage which is of great diagnos- 
tic value — namely, paralysis. Its presence affords strong evidence that there 
is extravasation of blood, and probably in a cavity of the substance of the 
brain. If the extravasation end in the formation of a cyst, the symptoms 
and appearance of hydrocephalus, which after a time arise, throw light on 
the nature of the disease. 

Prognosis. — There can be no doubt that many cases of intracranial hem- 
orrhage occur and terminate favorably without the nature of the disease being- 
suspected. In such cases the amount of extravasated blood is small or mod- 
erate. In several published cases in which the accuracy of the diagnosis 
was shown by post-mortem examinations, the patients were convalescing 
from the hemorrhage when they succumbed to intercurrent diseases. If, 
however, the amount of extravasated blood be such as to give rise to those 
symptoms which have been described, the prognosis is unfavorable. Recur- 
ring convulsions and persistent stupor from which it is difficult to arouse the 
patient are unfavorable symptoms. If the convulsions cease and conscious- 
ness return, even if there be paralysis, the result may be favorable. 

Treatment. — The proper treatment in intracranial hemorrhage depends 
on the state of the patient, the time which has elapsed since the extravasation, 
and the degree of it as shown by the nature and severity of the sj^mptoms. 
If, as is often the case, the patient be robust and be visited soon after the 
commencement of the attack, cold applications should be made to the head, 
mustard to the back of the neck and perhaps chest, and derivation should 
be produced by mustard pediluvia. In many cases, especially in active con- 
gestion, it is advisable to apply leeches to the temple and the bowels should 
be opened by a stimulating enema. In active congestion also prompt purga- 
tion by salines or other cathartics is sometimes of great importance. The 
object of such treatment is to relieve congestion of the cerebral and menin- 
geal vessels, and thereby prevent further extravasation of blood. If the 
congestion be active, the pulse continue full and frequent, and the face be 
flushed, it is proper in many cases to control the action of the heart by a 
sedative. For this purpose the tincture of aconite-root may be given in 
doses of one drop to a child five years old, repeated in three hours if 
necessary, or antipyrine or phenacetin. If the stupor or convulsions con- 
tinue after sufficient time have elapsed for the patient to receive the full 



542 CONGENITAL HYDROCEPHALUS. 

benefit of the above remedies, more counter-irritation is required. Cantlia- 
ridal collodion should be applied behind each ear. If the hemorrhage occur 
from passive congestion or in a cachectic state of system, active depressing 
remedies should not be employed. External derivatives are of service, as 
well as cool applications to the head, and we should attempt, as far as possi- 
ble, to remove the cause of the congestion and hemorrhage. If it depend 
on a cachectic state, tonic or other remedies calculated to relieve this state 
are indicated. The hemorrhage from such a cause is usually in points in 
the substance of the brain or in moderate quantity over the surface of this 
organ, and by a timely use of constitutional remedies possibly we may pre- 
vent further extravasation of blood and increase the chance of the patient's 
recovery. 

If a cyst result from the hemorrhagic effusion, the treatment which is 
proper is that described in the chapter on Acquired Hydrocephalus. 



CHAPTER VI. 

CONGENITAL HYDEOCEPHALUS. 

Congenital hydrocephalus consists in an excess of the cerebro-spinal 
fluid, lying either external to the brain or more frequently in its interior. 
It is due to some vice in the development of the brain or its membranes or 
to a pathological state occurring in them during intra-uterine life. This dis- 
ease is in some patients apparent from the symptoms and appearances at birth, 
but not always. Occasionally nothing unusual is observed in the shape of 
the head or aspect of the infant till after the lapse of some weeks, when the 
characteristic physiognomy begins to appear, In these cases the disease is 
still congenital, since there is every reason to believe that the abnormal state 
to which the excessive production of fluid is due existed from birth. In cases 
of arrested or partial development of the brain — as, for example, when a con- 
siderable portion of the hemispheres is absent — there is often an unusually 
large quantity of fluid which serves as a compensation for the lack of brain. 
I do not regard such cases as examples of hydrocephalic disease, since the 
efl'ect of the fluid is not injurious, but rather useful. I restrict the term 
congenital hydrocephalus to those cases in which the brain is complete, or, 
if incomplete, the quantity of fluid is more than suflicient to supply the 
deficiency. 

Anatomical Characters. — According to M. Breschet, the fluid in con- 
genital hydrocephalus may be — 1st, between the dura mater and the cranium ; 
2d, between the dura mater and the parietal arachnoid ; 3d, in the cavity of 
the arachnoid ; 4th, in the ventricles ; 5th, between the arachnoid and the 
brain. 

In a large majority of hydrocephalic patients the efl"usion occurs in the 
ventricles. As the quantity of fluid increases the pressure from .within 
gradually unfolds the convolutions of the brain, at the same time producing 
expansion of the cranial arch. When the amount of fluid is considerable — 
and it becomes so in the course of a few weeks or months — the hemispheres 
are spread out in a thin lamina on either side, gradually decreasing in thick- 
ness from the base of the cranium to the vertex, where the brain-substance 
is sometimes so thin as to be scarcely perceptible. Complete absence of brain 
in this situation — namely, at the vertex, even in extreme cases of expansion 



A XA TO MICA L CHA RA CTERS. 



543 



and flattening of the hemispheres from the pressure of the liquid — is rare, 
though the brain-substance at this point is sometimes almost as thin as either 
of the membranes, so that the wall of the sac is translucent. The mem- 
branes which surround the brain do not usually undergo an}- alteration, 
except such as arises from the distension. The falx cerebri sometimes dis- 
appears, and sometimes the meninges present a whiter hue from maceration 
than in health. The distension also causes such an expansion of the pia 
mater that it becomes very thin, and in places scarcely visible, but its pres- 
ence in every point can be demonstrated. 

The accompanying woodcut represents congenital hydrocephalus as it 
ordinarily occurs. I saw this infant when it was a few days old, and 
examined it from time to time till its death. The parents are healthy and 
have other healthy children. This infant when nine days old began to have 



Fig. 34. 




I ^ r 
^^ \\\f X" / 




clonic convulsions of a mild form in the muscles of the face, neck, and limbs, 
which occurred almost daily till the age of six weeks, and sometimes every 
five or ten minutes. When the convulsions ceased in the sixth week the 
head was observed to enlarge, and its excessive growth continued till death, 
which occurred at the age of seven months and one week. While the vol- 
ume of the head progressively increased, the trunk and limbs emaciated. 
At death the occipito-frontal circumference of the head was nineteen and a 
naif inches ; the vertical from auditory meatus to meatus thirteen and a half 
inches. 

The changes which the cranial bones undergo, both in their chemical 
character and in their shape in hydrocephalic patients, if the amount of fluid 
be considerable, are interesting and remarkable, The base of the cranium 
undergoes little change, but those portions of the frontal, parietal, and occip- 
ital bones which constitute the arch are expanded in all directions, while they 
become much thinner. There is deficiency of lime in their constitution, so 
that the organic elements are greatly in excess. This renders them flexible 
and semi-transparent. Notwithstanding the expansion of the bones, there 
are usually interspaces between them, of greater or less size according to the 
amount of fluid. 



544 CONGENITAL HYDROCEPHALUS. 

The scalp, being stretched by the pressure underneath, becomes tense and 
thin, and is scantily covered with hair. The veins which ramify in it are 
unusually prominent and large, and the head is elastic on pressure from the 
amount of liquid beneath. In the common form of congenital hydrocephalus 
— namely, that in which the liquid is in the interior of the brain — the shape 
of the orbital plates of the frontal bone is often changed, so that the eyeballs 
have a downward direction. This change in the' axis of the eyes occurs at 
an early period, and it continues through the entire disease, becoming more 
and more marked as the quantity of liquid increases. If the amount be 
large, the lower part of the cornea is buried under the under eyelid, while 
the conjunctiva is visible between the cornea and the upper eyelid. The per- 
sistent downward direction of the eyes is characteristic of this disease, and in 
connection with enlargement of the head is an important diagnostic sign. 
Nevertheless, hydrocephalus, even of the ventricular variety, sometimes 
occurs without change in the direction of the eyes. 

If we examine the interior of the cavity after the fluid is evacuated, we 
will find at its base the parts which lie in the floor of the lateral ventricles, 
but changed in appearance in consequence of pressure. The cornua are 
enlarged and the thalami optici and corpora striata are flattened. In the 
early stages of the disease, when the amount of fluid is small, there is prob- 
ably no absorption or destruction of parts in the interior of the brain. The 
various portions of this organ retain nearly their normal relation to each 
other. As the quantity of fluid increases the foramen of Monro, which 
unites the lateral ventricles, becomes enlarged, the septum lucidum which 
separates them disappears, and the two ventricles form a common cavity. In 
most fatal cases we find this single large cavity. The surface which sur- 
rounds the cavity occasionally presents a whitish or semi-opaque appearance, 
which has led to the belief that at a period antecedent to birth there was sub- 
acute inflammation of this surface, and hence the efl"usion. 

The bones of the face are ordinarily less developed than in healthy chil- 
dren of the same age, so that the disproportion between the head and face 
becomes a marked peculiarity. The shape of the forehead and f^ce is nearly 
triangular. 

The foregoing remarks in reference to the anatomical characters of con- 
genital hydrocephalus refer in the main to cases which have continued for a 
considerable time, so that their characteristic features are well marked. In 
very young infants, in whom the disease is still recent, similar anatomical 
characters are present, but in less degree. 

Congenital hydrocephalus is often associated with other vices of confor- 
mation, especially with spina bifida. The two, when coexisting, are only 
parts of the same disease, the large quantity of cerebro-spinal fluid prevent- 
ing the spinal canal from closing during foetal development. 

The fluid in congenital hydrocephalus consists largely of water, in the pro- 
portion even of 99 parts in 100. In addition to this element there are traces 
of albumen, chloride of sodium, phosphate and carbonate of sodium, and 
osmazome. 

I have had an opportunity to witness only one post-mortem examination 
in a case of congenital hydrocephalus in which the liquid was exterior to the 
brain. This case was under observation in the children's service of Charity 
Hospital in 1866. Full notes and measurements of the head were taken, 
which, unfortunately, were mislaid or lost. The infant had congenital syph- 
ilis and had a pallid, strumous appearance. The shape and relative size of 
the head are seen in the woodcut (Fig. 35), from a photograph. While 
the whole head was enlarged, there was a relative excess of development in 
the part between and above the ears. The axis of the eyes was not at all 



ETIOL G Y—S YMPTOMS. 



545 




changed, and the vision was good. The appearance corresponded so closely 
with descriptions of hypertrophy of the brain that this was supposed to be 
the anatomical state. Antisyphilitic treatment was employed, and the syph- 
ilitic eruptions had nearly disappeared when diarrhoea supervened, followed 
by death. At the autopsy a quantity of trans- 
parent or light straw-colored liquid, estimated at 
six or seven ounces, was found exterior to the brain 
in the great cavity of the arachnoid, lying mostly 
over the superior surface of the organ. There was 
no excess of liquid in the ventricles, and the brain, 
though of good size, was not abnormally large, nor 
did it possess the firmness which is present in true 
hypertrophy. 

All cases of congenital hydrocephalus may be 
embraced in two groups — namely, that in which 
the liquid is in the interior of the brain, and that 
in which it lies exterior to the organ. Liquid 
primarily in the arachnoidean cavity permeates 
the meshes of the pia mater, and lies in part un- 
derneath it, or this delicate membrane may be rup- 
tured. Four of the groups, therefore, described by Breschet, may properly 
be reduced to one — namely, those groups in which the liquid lies under, 
between, or external to the meninges. It is probable that some of the cases 
which led to Breschet's classification were examples of acquired circumscribed 
hydrocephalus, the result of extravasation of blood. In this form of hydro- 
cephalus, as is stated elsewhere, an adventitious membrane forms external 
to the liquid, becoming in time thin and delicate and often bearing a close 
resemblance to the normal membrane (especially the arachnoid), for which 
it is sometimes mistaken. 

Etiology. — The constitutional vice which gives rise to this disease is 
probably different in diff"erent cases. I have been able, I think, to attribute 
correctly a considerable proportion of cases which I have observed to con- 
genital syphilis, but in other instances from the character of the parents I 
could not assign this cause. 

Symptoms. — If there be a considerable amount of hydrocephalic fluid 
prior to the birth of the child, so that the head is abnormally large, partu- 
rition is seriously interfered with. The scalp and meninges may become 
ruptured by the severity of the pains, so that the fluid escapes. If this do 
not occur the labor is often necessarily instrumental. Whether the liquid be 
present before birth or accumulate subsequently to it, the tendency is to an 
increase of the quantity and a corresponding enlargement of the head. 

The digestive function in this disease is at first well performed. The 
infant nurses readily and has its evacuations with the regularity of other 
children. Xot many weeks, however, elapse, in the majority of cases, before 
defective nutrition is apparent. 

While the volume of the head increases other parts are imperfectly nour- 
ished and stunted in their growth. Emaciation of the neck, trunk, and 
limbs is common, associated with progressive feebleness. In the last stages 
of this disease there is more or less vomiting, with constipation. If there 
were previously the ability to support the head, it is now lost and the erect 
position is no longer possible. In marked cases, when there is great dispro- 
portion between the head and the rest of the system, there is frequently not 
even the ability to rotate the head on the pillow. So long as the cranial 
bones yield readily to the pressure from within and there is no compression 
of the brain, the function of this organ is not seriously impaired. The child 
35 



546 CONGENITAL HYDROCEPHALUS. 

recognizes its mother or nurse, and it can be amused like other children, 
though easily fatigued. The state of the senses is different in different cases, 
and sometimes at different stages of the same case. The sight and hearing 
in some are perfect, in others impaired, while in others still they are good at 
first, but graduall}' become obscured and lost. It is said that the sense of 
smell may be perverted, so that agreeable odors are unpleasant, and vice versa. 
Many, reaching the age at which children begin' to walk, cannot walk, or if 
they do it is with a tottering, unsteady gait. 

When the liquid increases to that extent — and it usually does sooner or 
later — that the brain begins to be compressed, dangerous cerebral symptoms 
arise. The child becomes drowsy and takes less notice of objects. Spas- 
modic muscular contractions, and finally convulsions, occur. The pupils act 
feebly or irregularly by light, or one is more dilated than the other. Strabis- 
mus also occurs. As death approaches, eclampsia, partial or general, becomes 
more frequent, and is succeeded by stupor from which the patient cannot be 
aroused. 

The following case, which I copy from my note-book, is an example of 
the common form of congenital hydrocephalus ; it will give an idea of the 
ordinary course of this disease, and show the difficulty which we meet with 
in its treatment : Female, born November 9, 1859, with the aid of forceps. 
At birth the fontanels were unusually large, the cranial bones separated, and 
the aspect in a marked degree hydrocephalic. She nursed at first, but, the 
mother's milk failing, she was afterward bottle-fed. At the age of four 
months her head, which had increased faster than her general growth, meas- 
ured from one auditory meatus to the other, over the vertex, seventeen inches ; 
the occipito-frontal circumference, twenty-three inches. At this time she 
manifested considerable intelligence, being able to distinguish her mother 
from other persons, though the head was so large that it was necessary to 
support it constantly on a pillow. From the age of four to six months the 
operation of tapping was performed six times with a small hydrocele trocar 
by Dr. Stephen Smith, at a point near the coronal suture and from one inch 
to one inch and a half from the sagittal. At each operation an amount of fluid 
varying from twelve ounces to one pint was removed, and the head then cov- 
ered with strips of adhesive plaster, so as to form a complete cap. It was 
necessary, however, within the twelve hours succeeding each operation to loosen 
the dressing on account of either the occurrence of convulsions or symptoms 
premonitory of them. The head within a week subsequently to each opera- 
tion regained its former size, and, as there was no permanent benefit, this 
treatment was discontinued. She finally died of entero-colitis at the age of 
ten months and five days. 

At the autopsy the distance from one auditory meatus to the other was 
twenty and a quarter inches ; ,the occipito-frontal circumference, twenty-six 
and a quarter inches. The anterior fontanel measured antero-posteriorly 
four and three-fourths inches ; transversely, seven and three-fourths inches. 
The parietal bones were separated from each other to the distance of two or 
three inches, and they measured in length nine and a half inches. 

On opening the cranial cavity, seven pints, by measurement, of trans- 
parent fluid escaped, exposing a vast open space at the bottom of which 
were the parts which constitute the floor of the ventricles, somewhat changed 
in shape, and from them on either side the hemisphere was spread in a 
lamina, so as to cover the internal surface of the cranial bones. The laminae 
near the base of the brain measured in thickness from half an inch to one 
inch, and they gradually became thinner on approaching the vertex, at which 
point the brain-substance was exceedingly thin, so as to be scarcely demon- 
strable. 



DIAGNOSIS— TREATMENT. 547 

The brain had its normal vascularity and consistence, and the cerebellum, 
medulla oblongata, the base of the brain, and cranial nerves presented their 
usual appearance. On folding the brain together it had the size, shape, and 
aspect of this organ in its ordinary development. Nothing unusual was 
observed in the membranes except their great expansion. The above case 
corresponds in its general features with most cases met in practice. 

Diagnosis. — The ordinary form of congenital hydrocephalus, that in 
which the liquid occupies the interior of the brain, can in most cases be 
readily diagnosticated. If there be only a moderate amount of liquid, it 
may be confounded with hypertrophy of the brain. In hydrocephalus there 
are commonly more rapid growth and greater expansion of the head ; more- 
over, the enlargement occurs equally on all sides, while in hypertrophy, 
though all parts of the cranial vault are expanded, the enlargement is more 
at the vertex than elsewhere. The hydrocephalic head yields more readily 
to pressure than the hypertrophied, and often communicates a fluctuating 
sensation. Moreover, in the ordinary form of hydrocephalus the change in 
the axis of the eyes described above is an important diagnostic sign. In 
rachitis the volume of the head is often considerably enlarged, due some- 
times, in part at least, to a deposit of calcareous matter on the exterior of 
the cranial bones. The differential diagnosis is based on the shape of the 
head, round in one, square or with prominences in the other, on palpation, 
direction of the eyes, etc. The smaller the amount of liquid, the greater the 
liability to error of diagnosis ; but if the amount be inconsiderable and not 
increasing, little treatment is required except hygienic and tonic, which is 
also proper in both hypertrophy and rachitis. If the liquid be exterior to 
the brain, as in the case represented in Fig. 35, diagnosis may be difficult, but 
such cases are infrequent. 

Prognosis. — In the majority of cases this is unfavorable, since the secre- 
tion of liquid usually continues. The most favorable result is no increase, or 
but slight, in the quantity, while the natural growth of the infant increases, 
and thus the disproportion between the head and the rest of the system 
gradually disappears. Such patients may live to maturity and have tolerable 
health, and may engage in occupations. But ordinarily in cases left to 
themselves, and even in a large proportion of those having the best treatment, 
the body and limbs gradually waste from defective nutrition, and the patient, 
if not cut off by an intercurrent disease, finally succumbs with cerebral symp- 
toms produced by pressure of the liquid. Probably more than half of the 
hydrocephalic patients die before the close of the second year. 

Treatment. — We may attempt to diminish the quantity of fluid by the 
use of diuretics. Digitalis, squills, nitrate and acetate of potassium have 
been used. The most efficient diuretic in these cases, however, is the iodide 
of potassium. This may be given in doses of one to two grains every two 
hours to an infant of three months. Constipation, if present, should be 
relieved by an occasional purgative. If it be tolerat^ed, we may partially 
prevent the expansion of the head by a close-fitting cap. For this purpose 
strips of adhesive plaster about one-third of an inch in width should be applied 
so as to cover the entire head. The proper way of applying these is as fol- 
lows : First, one strip from each mastoid process to the outer part of the orbit 
on the opposite side ; secondly, from the back of the neck, along the longi- 
tudinal sinus, to the root of the nose ; thirdly, over the whole head, so that 
the different strips will cross each other at the vertex ; and, lastly, a strip 
long enough to pass three times around the head should be applied, passing 
above the eyebrows, the ears, and below the occipital protuberance. Too 
tight an application should be avoided, as it may give rise to convulsions or 
other cerebral symptoms. If the cap can be tolerated and the general health 



548 ACQUIRED HYDROCEPHALUS. 

be good, the prospect is more favorable ; but usually, from the increase in the 
quantity of fluid, it is necessary in a few days to remove or loosen the strips 
in order to prevent convulsions, or, which is preferable, to diminish the size 
of the head and relieve the pressure by tapping. In 56 cases collected by 
Dr. West in which tapping was employed, 4 recovered. The operation is 
simple, easily performed, devoid of danger, and it frequently gives temporary 
relief. It should therefore be recommended to the parents, even if it do not 
effect a cure. It should be performed by a very small trocar, which should 
be introduced in the coronal suture, about an inch external to the anterior 
fontanel. A few ounces should be removed, and strips of adhesive plaster or 
an elastic skull-cap applied. In a few days the operation should be repeated 
as the liquid increases. It is important to maintain compression of the skull 
before and after the operation (Treves). Sometimes a dozen or more tap- 
pings are required at intervals of a few days or weeks, when the secretion 
may come to a standstill. In the Med.-C fur. Trans. (1864) a case is related 
in which two tappings effected a cure, but so good a result is exceptional. 
Iodine injections in connection with tapping have so far not produced any 
satisfactory result. Sir James Paget ^ relates a case in which he injected ten 
grains of iodine and twenty grains of iodide of potassium in one ounce of 
water, but the child died of convulsions after the second injection. No appre- 
ciable good result has followed the use of irritating or sorbefacient applica- 
tions to the head. Nutritious diet and attention to the general health are 
requisite. 



CHAPTEK VII. 

ACQUIEED HYDROCEPHALUS. 

Hydrocephalus, or dropsy of the brain, may also occur in those who at 
birth are well formed and free from disease. Pathologists call this acquired 
hydrocephalus. It is in nearly all cases the result of disease, which is located 
sometimes within the cranium, but often in other parts of the system. 

Causes. — The diseases within the cranium which most frequently produce 
serous effusion are the meningeal inflammations, both simple and tubercular, 
tumors or other causes which obstruct the venous circulation, and hemor- 
rhagic effusion ending in the formation of cysts. Prolonged passive con- 
gestion often ends in transudation of serum through the coats of the capil- 
laries. Therefore, all causes of congestion, except such as have a transient 
or momentary effect, may be regarded as causes of serous effusion. In rare 
instances chronic hydrocephalus results from cerebro-spinal fever (meningitis), 
as has been stated in my remarks on the latter disease. 

Among the diseases external to the cranium which produce serous effusion 
within or upon the brain may be mentioned retropharyngeal abscess, tuber- 
culization or inflammation of the bronchial glands, scarlet fever, and certain 
affections of an exhausting nature, especially protracted diarrhoeal maladies. 
In at least five cases which have fallen under my notice, and in which post- 
mortem examinations were made, the cause was enlarged tubercular bronchial 
glands, which, by pressure on the venae innominatse, so retarded the flow of 
blood from the brain as to cause congestion and effusion. The causal relation 
of these glands to cerebral congestion is described in our remarks in reference 
to this disease. 

^ Medical Times and Gazette, 1860. 



ANATOMICAL CHARACTERS— SYMPTOMS. 549 

Dropsy of the brain is common in protracted infantile diarrhoea ; as, for 
example, in advanced cases of intestinal catarrh of the summer months in 
the cities. It is preceded and accompanied b}' passive congestion of the cere- 
bral veins and sinuses, due in part to feebleness of circulation in consequence 
of the exhausted state of the patient, and in part to wasting of the brain, 
which always give rise to more or less passive congestion, unless in young 
infants, in whom the cranial bones become depressed and override each other. 
Dropsy of the brain, resulting from scarlet fever, and that peculiar circum- 
scribed dropsy which results from hemorrhagic effusions, are described else- 
where. 

A few cases have been related by different observers, Abercrombie among 
others, in which dropsy of the brain seemed to be essential. Nothing abnor- 
mal was observed, with the exception of serous effusion. But the reports of 
such cases are, for the most part, meagre, and, as Barrier has well said, we 
are not to accept such cases as examples of essential dropsy of the brain 
unless the post-mortem inspection be so complete as to render it certain that 
there was no pathological state which might cause the dropsy. 

Anatomical Characters. — Acquired hydrocephalus usually occurs 
after the cranial bones are firmly united, and therefore the shape of the 
head is not materially altered. If it occur at any early age, before there is 
free union, there may be expansion of the cranial arch, as we sometimes 
observe in the circumscribed hydrocephalus resulting from hemorrhage. 
The effusion in acquired hydrocephalus occurs over the surface of the brain, 
in the subarachnoid space, or in the lateral ventricles. In the dropsy of pro- 
tracted diarrhoeal maladies I have rarely failed to find the liquid over the 
whole superior surface of the brain as well as at its base. 

The quantity of fluid in this disease is not large. In the majority of 
cases it does not exceed four ounces, and is often much less. It is transpar- 
ent or it has a slightly yellowish tinge. The membranes of the brain some- 
times present their normal appearance, but in other cases they are injected. 
The brain itself in some instances has an injected appearance from passive 
congestion of the veins and capillaries ; but in others, when there has been 
more or less compression of the brain, there is no more than the ordinary, or 
even less than the ordinary, vascularity, and the convolutions are somewhat 
flattened. 

Symptoms. — The symptoms of the pathological state which gives rise to 
the dropsy precede and accompany those which are referable to the dropsy 
itself. The dropsy declares itself by symptoms which are alarming from 
the first. 

In children old enough to speak or manifest intelligence there may be at 
first complaint of headache. The child is irritable, its mind confused or wan- 
dering at times, or there is actual delirium. After a time drowsiness occurs. 
The head seems too heavy for the body and is buried in the pillow. In fatal 
cases the features become pallid, the pupils sluggish, and perception and 
consciousness are gradually lost. The child lies in profound sleep, which 
increases. There are now often convulsive movements, partial or general, 
and these soon end in coma, in which the patient dies. 

The following was an interesting case of acquired hydrocephalus which 
seemed to result from subacute meningitis. The patient was seen by several 
physicians, and the diagnosis was for a long time doubtful : 

Harry E,. L , of healthy parentage, was well till the summer of 1876, 

when he was nearly at the close of his third year. At this time he was 
observed to be feverish and fretful and his features were flushed at times. 
He also complained almost daily of pain in the top of his head, which pain 
was intermittent, and these attacks of headache occurred durino- at least six 




550 ACQUIRED HYDROCEPHALUS. 

months, perhaps longer. There had been no backwardness in dentition and 
no symptoms of rachitis or struma, and his nutrition was good even after 
the commencement of the present malady. 

In February or March, 1877, his stomach became irritable, so that he 
vomited often during the following months, and about the same time he 
began to lose the use of both legs — a progressive paralysis — and his bowels 
became constipated. Both urination and defecation were sluggishly per- 
formed. In July, 1877, he ceased to walk, and he has not been able to 
stand since. 

On March 29, 1878, the following records were made: No improvement, 
but gradual increase of most of the symptoms ; lies constantly ; moves his 
limbs slowly and infrequently, but completely, and sensation appears to 
remain in all of them ; his eyes are clear and his pupils moderately dilated, 
but without vision — how long his sight is lost is 
Fig. 36. not known ; axis of eyes not depressed or other- 

wise changed, and parallelism retained ; the cranium, 
which during the first year of his sickness under- 
went little change, has expanded rapidly during the 
last six months ; the enlargement is most marked 
above the ears ; the occipito-frontal circumference 
is represented in the accompanying diagram ; this 
circumference measures twenty-one and a half inches, 
of which nine and three-quarters are in front of ears, 
and eleven and one-third inches posterior to ears ; 
distance over vertex from one auditory meatus to 
the other, fifteen and a quarter inches. The anterior fontanel is observed to 
be open, though small, the diameter being about one-fourth or one-third of 
an inch ; it is not elevated and the surrounding edge of bone is flexible. 

This patient lived till near the close of 1880 without material change in 
symptoms, and with moderate progressive increase in the size of the head. 
At the autopsy measurements were again made, but they have been mislaid. 
The enlargement was found to be due to the presence of about three pints 
of straw-colored serum in the lateral ventricles, which had been changed into 
a large cavity. There was nothing to indicate any other disease. From the 
history and appearances we inferred that the hydrocephalus had been due to 
a mild meningitis occurring in the third year. The appearance and state of 
the encephalon were precisely like those in ordinary congenital hydrocephalus. 
In January, 1890, I exhibited to the New York Paediatric Society a child 
with acquired hydrocephalus which dated back to an attack of cerebro-spinal 
fever of mild type which occurred a few months previously. It seems to me 
that the case detailed above resulted from the same disease. 

Prognosis. — Acquired hydrocephalus commonly ends unfavorably. The 
prognosis depends not only on the quantity of liquid, but on the nature of 
the cause. If the cause be venous obstruction within the cranium or thorax, 
death is inevitable, since we have no means of removing it. If it be an exhaust- 
ing disease, as entero-colitis or scarlet fever, although the case is not abso- 
lutely hopeless, the prospect is still unfavorable. It is only favorable when 
the quantity of effused fluid is small, the system not much reduced, and the 
primary disease mild. When acquired hydrocephalus arises from meningeal 
apoplexy, the case is usually chronic. The symptoms and termination of 
this form of the disease are very similar to those in congenital hydro- 
cephalus. 

Treatment. — The treatment in acquired hydrocephalus must vary some- 
what in difi"erent cases, according to the nature of the disease on which it 
depends. I shall indicate the treatment, in part at least, in the description 



MEXIXGITIS. 551 

of these diseases. Occasionally the condition of the patient is such that 
there is little to encourage us in the employment of any remedial measures. 
In vigorous children, if acquired hydrocephalus occur in connection with 
symptoms which indicate too active a circulation, moderate abstraction of 
blood from the temples at an early period may be useful, but cases requiring 
such depletory measures are rare. These cases require cold applications to 
the head ; the bowels should be opened, and derivatives should be applied to 
the feet and back of the neck. 

If the congestion be of a passive character, as when the circulation is 
obstructed by tumors or otherwise, benefit may still be derived from cold 
applications to the head and derivatives to other parts. In most cases of 
suspected dropsy of the brain, unless the patient be in such a hopeless state 
that all treatment is obviously futile, vesication should be produced behind 
the ears. I prefer cantharidal collodion for this purpose. In addition to this 
treatment, diuretics should be employed, unless there be too great prostration 
or the course of the disease be so rapid that no benefit can result in conse- 
quence of the tardy action of these agents. The best diuretics are the 
acetate of potassium and iodide of potassium. 



CHAPTEE YIII. 

MEXIXGITIS (TUBEECULAK AXD XOX-TUBEKCULAE). 

The most interesting and important disease of the cerebro-spinal system 
in early life is that which is now designated. meningitis. It is not infrequent. 
The mortuar}^ statistics of this city show that it is the cause of death in from 
1 in 25 to 1 in 50 of the entire number of deaths, the proportion varying 
somewhat in different years. 

In 1768 the attention of the profession was particularly called to this 
malady by Dr. Whytt of Edinburgh. This observer and the pathologists 
succeeding him, forming their opinion of meningitis from its most prominent 
anatomical character — namely, serous effusion — believed it a dropsy. They 
accordingly designated it acute hj'drocephalus. During the last half century 
the profession have come to regard the disease as inflammatory, and hence 
the name by which it is now known and which is believed to express its true 
pathological character. 

Sometimes meningeal inflammation in children occurs without tubercles. 
In other instances it results from the presence of tubercles, and in most if 
not in all such patients there are tubercles in or under the meninges, which 
excite the inflammation in the same manner as in the lungs they cause pneu- 
monitis or pleuritis. Therefore two forms of meningitis are recognized — 
to wit, tubercular and non-tubercular. Meningitis is also, as we have seen, 
the characteristic anatomical character of cerebro-spinal fever, but as this is 
a general disease, with the meningitis as a local manifestation, we have treated 
of it at length among the constitutional maladies. 

In patients over the age of eighteen months, although the proportion of 
tubercular to non-tubercular cases is larger than under this age, the excess is 
not so great, according to my statistics, as the remarks of some observers lead 
us to suppose. There can be no accurate statistics of tubercular meningitis 
without careful post-mortem examination of the state of the brain and other 
organs in each supposed case, and this examination sometimes shows the 



552 MENINGITIS. 

meningitis to be non-tubercular wben the symptoms and signs had indi- 
cated its tubercular character. As an example may be mentioned a case 
which occurred in the children's service of Charity Hospital in March, 1868. 
The infant died at the age of twenty months, having had a cough of mod- 
erate severity at least three weeks before death, and symptoms of meningitis 
about four days. It was considerably wasted, and was supposed to have 
tuberculosis. At the autopsy no tubercles were found in any part of the 
body, but portions of both lungs were hepatized. A fibrinous deposit, vary- 
ing in thickness, was found over the pons Varolii, the optic commissure, along 
the fissures of Sylvius, over the superior surface of the anterior half, and also 
upon the superior lobe of each cerebral hemisphere. As the examination 
failed to discover any tubercles, the meningitis was considered non-tubercular. 
Those who make these examinations, failing to find tubercles in the lungs and 
other organs in which they usually occur, should examine the lymphatic 
glands, since cheesy glands may be the cause of the formation of tubercles 
in the meninges, while the organs of the trunk remain unaffected. The 
presence of cheesy glands in the absence of visceral tubercles, and with 
granulations upon the meninges, small, covered with fibrin, and of a doubt- 
ful character, goes far toward establishing the tubercular nature of the 
meningitis. Since the cases embraced in the following statistics were 
observed, now more than twenty years, I have been led by a more extended 
experience, and especially by the observations of cases in the New York 
Foundling Asylum, where there is ample material, to regard not only the 
presence or absence of tubercles, but also of caseous substance, as the proper 
test of the form of meningitis. Not a few that seem at first to have non- 
tubercular meningitis will be found, on more thorough examination, to have 
caseous substance in some part, the result of a pre-existing inflammation ; and 
if we regard the inflammation of the meninges occurring under such circum- 
stances as tubercular, the relative proportion of tubercular cases will be con- 
siderably augmented. The following is an example : When on duty in the 
asylum in August, 1881, an infant one year old died of meningitis. No 
tubercles were observed in the fibrin at the base of the brain and along the 
fissures of Sylvius, but one inflammatory nodule (cerebritis) as large as a 
chestnut, with suppuration inside, was found at the summit of one hemisphere. 
No tubercles could be detected in any of the organs of the trunk, unless a few 
whitish spots in the spleen were of this nature, but the bronchial glands were 
cheesy and softened, and the middle lobe of the right lung also contained 
cheesy substance. It seemed to me probable that some of this degenerated 
product taken up by the vessels had lodged in the meninges and produced 
the tubercular neoplasm there which was hidden under the fibrin, (See 
chapter on Tuberculosis.) 

Age. — The following table gives the age in meningitis, tubercular and 
non-tubercular, in forty-two cases in my collection, which of course is only 
a small proportion of those which I have observed ; but these are the onl}- 
cases of which I have preserved notes which are now accessible : 

Cases. Age. 

1 2j weeks (autopsy). 

2 3 months. 

20 From 3 to 12 months. 

10 From 1 year to 2 years. 

5 From 2 years to 5 years. 

4 ■ Over 5 years. 

42 
Rilliet and Barthez have also published statistics of the age in meningitis. 



PATHOLOGICAL AXATOMY. 553 

Their cases were observed chiefly in hospital practice, and the result is some- 
what different. In 32 cases of non-tubercular meningitis observed by these 
authors, 8 were under the age of one year, 6 from two years to five, and 18 
over the age of five years. In 98 cases of tubercular meningitis, 2 were 
under the age of one year, 51 between the ages of one year and five, 38 
between the ages of five years and ten, and 7 between ten and fifteen 
years. Gowers states that the age at which meningitis is most frequent is 
between the first and tenth years. 

Pathological Anatomy. — This differs considerably in different cases. 
The dura mater is usually unaffected or is affected secondarily. In many 
cases it retains its normal appearance, its internal surface remaining smooth 
and polished, while in others it is more or less injected and its internal surface 
dim or lustreless. The free surface of the pia mater, formerly designated 
the visceral arachnoid, is in a great part of its extent unchanged, but is often 
hyperasmic or dry and cloudy or opaque over the seat of inflammation. 
Exudation does not occur upon the free surface of the pia mater, how- 
ever intense the inflammation. 

In meningitis, tubercular and non-tubercular, the inflammator}" action 
occurs in the pia mater. In its meshes or underneath them those lesions 
result which characterize the disease, and to which other lesions are second- 
ary. Tubercular meningitis is most frequently basilar, or is basilar chiefly 
and primarily, although the inflammation may extend along the sides of the 
hemispheres. The meningitis is ordinarily most intense around the pons 
Varolii, in the subarachnoid space, and along the fissures of Sylvius, for the 
tubercular neoplasm occurs chiefly at the base of the brain and along the 
vessels. In non-tubercular meningitis the inflammation may also occur at 
the base. It may in young infants be quite diffuse, and of little intensity in 
any one place, producing, in addition to hyperasmia of the pia mater, slight 
cloudiness and a moderate or slight escape of leucocytes from the blood, 
these (pus-cells) being perhaps visible only under the microscope. In men- 
ingitis due to extension of inflammation from an otitis media the inflamma- 
tory action is intense, confined to the portion of the meninges nearest the ear, 
and is often attended by inflammation of the adjoining brain-substance, with 
perhaps the formation of an abscess. If the cause be exposure to the sun's 
rays or traumatism, the meningitis is usually at the summit of the brain. 

The exudation of fibrin is greatest along the course of the vessels and in 
the depressions between the convolutions, and the opacity is most marked in 
these situations. Pus, when present, is often semi-solid, from the small pro- 
portion of liquor puris which it contains, even in recent cases. If the dis- 
ease have continued several days, the liquor puris may be mostly absorbed, 
and the pus-cell, becoming shrivelled, irregular, and aggravated, may resem- 
ble closely the cheesy transformation of tubercle-cells. 

The fibrinous exudation presents features of interest. It does not 
usually attain much thickness, but by its opacity it conceals from view the 
brain underneath. If it occur in the fissures of Sylvius, the anterior and 
middle lobes are united by it. It is usually infiltrated through the substance 
of the pia mater. Sometimes little masses of variable size, often not as large 
as a pin's head, appear at the point of inflammation. These masses are firm, 
of a whitish color or a light yellow, and their number varies in difi'erent 
cases. They consist of a firm, homogeneous substance containing granular 
matter and cells which often bear a close resemblance to tubercle-corpuscles, 
but are distinct. These corpuscular bodies are plastic nuclei or plastic cells, 
often shrunken. It is seen, then, that there are two morbid products which 
may be mistaken for tubercle — one, pus which has been in great measure 
deprived of its liquid element, and which may resemble cheesy tubercular 



554 MENINGITIS. 

matter ; tlie other, plastic nuclei collected in little bodies, so as to resemble the 
ordinary form of crude tubercle. I once carried to one of the best micro- 
scopists and pathologists of this city some of the exudation from a case of 
meningitis, the cellular element in which could not readily be distinguished 
from shrunken tubercle-corpuscles. The exudation was from a child two 
years and eight months old, with good health previously to the meningitis, 
without tubercles in any part of the body, with parents healthy, and with no 
predisposition to tubercular disease. The microscopist, not knowing the 
history of the case or character of the family, and ignorant, like all of us at 
that time, of the true tubercle-cell, pronounced the exudation tubercular 
after a careful examination with the microscope. Bouehut says : " The 
whitish miliary granulations which are observed on the surface of the pia 
mater have a certain consistency and tenacity which render them difficult to 
tear with the needles used for the preparation for the microscope. These 
bodies are formed — 1. Of fibro-plastic elements, whether nuclei or fusiform 
fibres ; oval-shaped cells are generally present, but not always. The nuclei 
are oval or spherical, generally very small — that is to say, they hardly exceed 
in diameter 0.008 mm. to 0.009 mm. The presence of these little spherical 
nuclei must be insisted on, because with a less power than 550 diameters it 
would be sometimes impossible to establish the differences which separate 
them from the elements of tubercles •, the fusiform fibres are small and rare. 
2. There exists a considerable quantity of amorphous homogeneous matter 
in which minute granulations are scattered ; it is very dense, and keeps the 
other elements strongly united together, so that it is difficult to isolate them 
completely. 3. Vessels are very rarely observed ; the fibres of connective 
tissue are also rare or altogether wanting." 

In the tuberculosis of young children I have found in a large proportion 
of cases in which I have had an opportunity to make post-mortem exami- 
nations miliary tubercles disseminated through the lungs and perhaps other 
organs in small masses, many of them not larger than a pin's head, and some 
occurring as mere specks scarcely visible. These minute tubercular forma- 
tions have ordinarily been semi-transparent, and sometimes even transparent 
like minute drops of water, and containing the true and unchanged tubercle 
bacillus. Now, if in such a case meningitis occur, we may find the tubercle- 
cell in or with the fibrin at the base of the brain. But failure to find it, even 
with protracted microscopic examination, does not prove its absence from this 
locality, for I consider it almost impossible to discover in the midst of the 
fibrinous exudation such minute points of tubercular matter as are seen in 
the lungs, liver, or elsewhere. 

The pia mater is often firmly adherent to the brain at the seat of inflam- 
mation, so that on raising it a portion of the brain may be detached and 
removed with it. The extent of the inflammation varies much in difi"erent 
cases. There may in extreme cases be pretty general inflammation of the 
pia mater. In cases of such extensive meningitis the symptoms are usually 
severe and the course of the disease rapid. Thus, in the month of iVpril, 
1866, a girl eleven years of age, in the Protestant Episcopal Orphan x\sylum 
of this city, had complained occasionally of dizziness, but was otherwise in 
good health, cheerful, and with excellent appetite, till Thursday, when she 
was eff'ected with vertigo, more persistent than previously, and with head- 
ache. At 2 P. M. on the following day she was seized with general convul- 
sions, and continued insensible or nearly so, with occasional convulsive move- 
ments, till Monday, when she died comatose. The pia mater at the vertex, 
sides, and base of the brain had a cloudy appearance, and underneath it in 
places was a thick, creamy substance in small quantity, w^hich, examined by 
the microscope, proved to be pus, the largest amount being near the pons 



PATHOLOGICAL ANATOMY. 555 

Varolii. There was no tubercle under the meninges or elsewhere, and no 
appreciable fibrinous exudation. The meningitis, though of brief duration, 
was nearly general. The only additional lesions noticed were moderate con- 
gestion of the brain and an increase in the quantity of the cerebro-spinal 
fluid. 

If the disease be protracted three or four weeks, which is rare, or even 
less time, the exuded substance may undergo further changes, such as occur 
in simple exudations in other parts of the system. Thus, on the 30th of 
April, 1860, we made the post-mortem examination of an infant at the Nurs- 
ery and Child's Hospital who had symptoms of cerebral disease, it was stated, 
for several weeks, but the exact time was not ascertained. Prominent among 
the symptoms referable to the cerebro-spinal system toward the close of life 
were the hydrocephalic cry and rigidity of the neck. The appearance at the 
autopsy was remarkable. The anterior half of the brain was completely 
encased in a deposit which had nearly the appearance of lard. It filled the 
fissures of Sylvius and appeared slightly on the anterior aspect of the cere- 
bellum. Examined under the microscope, this substance was found to con- 
tain numerous cells, among which could be distinguished some resembling 
pus-cells, but nearly all had undergone more or less fatty degeneration. 
Here and there was seen a large cell containing numerous small oil-glob- 
ules, the compound granular cell of pathologists. 

The brain itself in meningitis is usually hypereemic. On making an 
incision through it red points are seen upon the cut surface, which indi- 
cate the seat of the congested vessels. The inflammation rarely extends to 
the walls of the ventricles, but the choroid plexus is injected. In excep- 
tional instances pus or fibrin is found in the lateral venticles. In the infant 
two and a half weeks old whose case has already been alluded to about two 
ounces of purulent fluid escaped on opening the left ventricle. A small 
amount of liquid of a similar character was contained in the right ventricle. 
The distension of the lateral ventricles with serum is one of the common 
results of meningitis. This fluid is clear or straw-colored, or it is turbid. 
The quantity does not exceed two, three, or four ounces, and is often not 
more than one ounce or an ounce and a half. The distension of the two ven- 
tricles is ordinarily uniform, as they are united by the foramen of Monro, 
but now and then one ventricle is found more distended than the other. If 
there be considerable eff"usion, the brain is compressed and the convolutions 
have a flattened appearance, unless the cranial bones are still separated so as 
to yield to the pressure. If the sutures and fontanels be open, the cranial 
arch is expanded, sometimes quite perceptibly to the eye. From the same 
cause the anterior fontanel, if open, is elevated. The foramen of Monro is 
enlarged according to the amount of eff"usion, and the portions of the brain 
which separate the ventricles are sometimes lacerated. In many cases the 
cerebral substance surrounding the lateral ventricles is softened. The soft- 
ening is found in all degrees, from the least appreciable deviation from the nor- 
mal consistence to a state of diflluence, so that the brain substance presents the 
appearance of cream. Hypotheses have been advanced to explain the cause 
of this change in consistence which are not entirely .satisfactory. Whatever 
the explanation, the fact is attested by all observers, though there are excep- 
tional cases. Thus Dr. West has records of the condition of the brain in 59 
cases, in 37 of which there was considerable softening, and in the remaining 
22 the consistence was normal. 

Since a majority of the cases of meningitis in children are basilar, and 
portions of all the cerebral nerves lie at the base of the brain, it is easy 
to understand why the functions of these nerves are so seriously impaired in 
this disease. Compression of these nerves or extension of inflammation to 



556 MENINGITIS. 

their sheaths affords explanation of many of the symptoms, as the sighing 
respiration, abnormalities of the eye, etc. 

Although the above remarks relating to the anatomical characters of men- 
ingitis are applicable to a large majority of the cases, I must confess that I 
have sometimes been disappointed at the autopsies of young infants who died 
with all the symptoms of meningitis in not finding more lesions. Moderate 
hypergemia of the pia mater, its slight opacity or cloudiness at the base of the 
brain or elsewhere, with the presence of a few wandering white corpuscles, 
without any fibrinous exudation, with no increase of liquid external to the 
brain, but a considerable increase of it in the lateral ventricles, and hyperaemia 
of the choroid plexus, with nearly natural appearance and consistence. of the 
brain, have in some instances been the only lesions when T had expected to 
find marked anatomical changes. 

I am fully convinced from my observations that in some instances phy- 
sicians who supposed that they were treating tubercular meningitis, and 
at the autopsies discovered within the cranium tubercles, without any inflam- 
matory lesion, but with a larger increase of the cerebro-spinal liquid, have 
been treating cases in which, in addition to the meningeal tubercles which 
were latent, the bronchial glands were tubercular and cheesy, so that by their 
increased size they compressed the venae innominatae within the thorax, thus 
preventing the free flow of blood from the brain, and causing, as I have else- 
where stated, cerebral and meningeal congestion, with more or less transuda- 
tion of serum, but with no meningitis. In tubercular meningitis the ana- 
tomical characters are like those in simple meningitis, with the addition of 
tubercles, which at first are minute and transparent, and are most easily 
detected when the inflammation has been slight. Seated in the pia mater, 
they cause some prominence of the arachnoid, and are best seen when so 
minute by an oblique light. 

Causes. — The causes of non-tubercular meningitis are not fully ascer- 
tained. Active cerebral congestion frequently occurring, however produced, 
appears to be one of the common causes in young infants. In at least three 
instances I have known meningitis to occur in infants between the ages of 
four and eight months after severe and protracted bronchitis, which had been 
attended with the usual heat of head. The disappearance of eruption upon 
the scalp at or immediately before the commencement of the meningitis 
has also been observed. I have witnessed it at the commencement of non- 
tubercular meningitis, as well as of meningitis which, if not tubercular, 
occurred at least in a decidedly scrofulous state of system. 

The direct efl'ect of the solar rays upon the head and the prolonged action 
of a high atmospheric temperature, even without direct exposure of the head 
to the sun, are common causes during the summer months in New York City. 
I once attended a child with this disease who had been much exposed bare- 
headed to the direct rays of the sun in August and September, and at his 
death, which occurred toward the close of the hot weather, found hypersemia, 
opacity, and fibrinous exudation in the pia mater at the summit of the brain, 
while the base of the brain seemed nearly or quite normal. 

Dr. Soltmann^ of Breslau reports three cases in which intense cerebral 
hyperaemia, and probably meningitis, occurred from solar heat. In all three 
children the attack was sudden, the febrile movement and heat of head intense, 
and the progress rapid. The first had convulsions, the second automatic 
movements, and the third, the oldest, aged four years, when able to speak 
complained of violent headache. 

The statistics of New York City show that congestive and inflammatory 
maladies of the brain and its covering are more common during July and 
^ Jahrbuch f. Kinder kraiik., for October. 1875. 



PREMONITORY STAGE. 557 

August, which are the months of maximum atmospheric heat, than in other 
months of the year. For example, in July and August, 1875, 167 died of 
these maladies, or 1 in every 9.8 who died from local disease, while during 
the entire year only 710 died from the same, or 1 in every 15 who perished 
from local diseases. 

July, 1876, in New York City was characterized by excessive and long- 
continued atmospheric heat, the temperature of the Central Park Observatory 
in the shade never falling below 61°, though never above 98°, and having a 
mean of 82.9°. There was also unusual dryness of the atmosphere, since 
during the entire month prior to July 30th there were only fourteen hours 
of rain with a rainfall of 0.77 of an inch, and the average atmospheric 
humidity was represented by 65, saturation being denoted by 100. During 
this month I treated in my private practice four fatal cases, all between the 
ages of two and seven years, which I diagnosticated meningitis, none of 
them presenting any symptoms of otitis or tuberculosis. It would seem 
that the atmospheric heat had much to do with the development of the dis- 
ease in these cases. One died in two days, but in the others there was the 
usual duration. Gowers also mentions insolation among the occasional causes. 

A not infrequent cause, especially among the strumous families of cities, 
is otitis media and caries of the petrous portion of the temporal bone, the 
inflammation extending to the meninges. Any suppurative inflammation 
occurring outside the dura mater, but in immediate proximity with it, may 
by extension cause meningitis ; but the most common cause of this kind 
is purulent otitis. The ex-ternal discharge of pus from the ear usually 
ceases when the meningitis begins. Gowers states that several cases are 
on record of meningitis occurring from traumatic inflammation of the eye, 
the inflammation probably passing along the sheath of the optic nerve. 
Gowers also states that the following acute diseases occasionally sustain a 
causal relation to meningitis : measles, scarlet fever, smallpox, typhoid fever, 
pneumonia, and acute rheumatism. But the meningitis occurring with or 
from pneumonia is probably cerebro-spinal fever, and meningitis occurring 
from the acute infectious diseases mentioned by Gowers is certainly rare, and 
perhaps its coexistence with them is in at least some instances a coincidence. 
Septic processes in any part of the system occasionally cause meningitis, 
probably from microbes, which, entering the circulation, are conveyed to the 
meninges. Since tubercular meningitis is due to the irritating eff"ect of tuber- 
cles in or under the pia mater, it usually occurs where tubercles are most 
abundantly developed ; that is, at the base of the brain and along the course 
of the vessels in the intergyral spaces. The inflammation is commonly excited 
when they are still small, even minute. 

Pre.monitory Stage. — Meningitis is usually preceded by symptoms 
which, if rightly interpreted, are of the greatest value. In most cases of 
this malady which I have seen there was a prodromic period varying from a 
few days to several weeks. The symptoms of this period are obscure, and are 
liable to be mistaken for those of other and distinct aff"ections. 

The child in whom meningitis is approaching loses his accustomed vivacity 
and cheerfulness. He has a melancholy and subdued appearance, being quiet 
a few minutes, and then fretful, without apparent cause. He can some- 
times be amused by his playthings or companions for a brief period, when he 
turns from them with evident displeasure. Unexpected and loud noises and 
bright lights are evidently painful. If old enough to describe his sensations, 
he complains of transient dizziness, and at other times of headache. His ill- 
humor, if his wishes are not immediately gratified or if they are denied, is 
often scarcely endurable on the part of friends who are ignorant of the cause. 
There is great difl"erence, however, in diff"erent cases as regards this symptom. 



558 MENINGITIS. 

Some are inclined to be taciturn and quiet, while others are almost constantly 
fretting. The appetite is capricious ; at one time it is pretty good, at another 
it is poor or even entirely lost. The patient may take a few mouthfuls of 
food, or if an infant may nurse a moment, when his hunger appears satisfied 
and he will take nothing more. The bowels are regular or inclined to con- 
stipation. The pulse is natural or it has times of acceleration, especially in 
the latter part of the day and toward the close of the premonitory stage. 
The duration of this stage is very different in different cases. Upon an 
average it is perhaps about two weeks, but is often longer. In tubercular 
meningitis the symptoms, both during the inflammation and previously, are 
often complicated by those which arise from tubercles in other parts of the 
system. 

Unless the prodromic period be of short duration the effect of imperfect 
nutrition is obvious before it closes. The flesh becomes soft and flabby or 
there is emaciation, though generally slight. The patient loses his strength, 
becoming less able to stand or to walk and more easily fatigued. Occasionally, 
especially in the non-tubercular form, premonitory symptoms are absent or 
are slight and of short duration. 

Symptoms. — Dr. Whytt, living in the last century, when the tendency 
was toward refinement rather than simplicity in classification, divided menin- 
gitis into three stages, according to the symptoms, especially the pulse. Many 
subsequent writers, following Whytt's example, have recognized three stages, 
based not upon the anatomical characters of the disease, but upon the suc- 
cession of symptoms. Such division of meningitis is in great measure arbi- 
trary, since in one case the same symptoms occur at an earlier period than in 
another. 

When the premonitory stage has passed and inflammation is developed, 
some of the symptoms which were previously present remain and are intensified, 
and other new and more characteristic symptoms appear. There are now fewer 
intervals of apparent improvement. The child is quiet, often lying with his 
eyes shut. If aroused he has a wild expression of the face and is irritated 
by attempts to engage his attention or amuse him. He rarely smiles or takes 
his playthings, or he notices them for a moment, when he turns away with 
disgust. During sleep there is often at first a placid expression of counte- 
nance, but when aroused he has the aspect of real sickness ; the eyebrows are 
sometimes contracted, as if from headache ; the features wear a melancholy 
look, and are turned away to avoid the gaze of the observer or to shun the 
light. If the anterior fontanel be open, it is observed to be prominent and 
pulsating forcibly. If consciousness be not lost and the patient be of suflicient 
age, he complains of headache or of pain in some part of the body. The 
tongue is moist and covered with a light fur ; the appetite is lost or poor ; 
there is seldom much thirst ; more or less nausea and constipation are pres- 
ent. As the inflammation continues, and usually within three or four days 
from its commencement, symptoms arise which dispel all doubts, if there were 
any, as to the nature of the disease. The vital powers are now evidently 
beginning to yield. The surface generally is more pallid, and there is the 
curious phenomenon of the sudden appearance — and after some minutes dis- 
appearance — of spots or patches, or even streaks, of active congestion upon 
the face, forehead, or ears. These, having a bright-red color, contrast strongly 
with the general pallor. Ordinarily they are irregularly circular or oval, and 
from one inch to an inch and a half in diameter. A red spot or streak is also 
produced if the finger be pressed upon the surface or drawn forcibly across 
it. It continues a few minutes, and then gradually fades. Trousseau calls 
attention to this fact as a diagnostic sign. It is known as the tCtche cerehrale 
of Trousseau, and it affords important aid in diagnosis. 



SYMPTOMS. 559 

Another curious phenomenon is the variation in temperature. The face 
and limbs at one time feel quite cool, and after some minutes, without any 
excitement or other appreciable cause, the temperature rises, so that the sur- 
face is warm to the touch. 

Consciousness in severe cases may be lost at an early period. On the 
other hand, I have known it in a case of moderate severity to remain, though 
partially obscured, till within twenty-four or thirty-six hours of death. The 
patient will usually open his mouth for drinks which are placed to his lips 
when there is no other evidence of intelligence and when sight and hearing 
are evidently lost. 

The loss of the senses constitutes an interesting but melancholy feature 
of the disease. Among the first unequivocal signs, and frequently the very 
first, are such as pertain to the eye. This organ should be watched from day 
to day when the diagnosis is uncertain. Deviation from its normal state afi"ords 
evidence of meningitis. The pupils are seen to dilate or contract sluggishly 
by variations in the intensity of the light, or they are not of the same "size 
with those of another individual to whom the same amount of light is admit- 
ted. Sometimes the first perceptible deviation from the normal state is an 
inequality in the size of the pupils, while in others oscillation of the iris is 
observed. Later, when convulsions have occurred, the parallelism of the 
eyes is lost. After effusion has taken place the pupils are commonly dilated. 
x\s death approaches the eyes become bleared and a puriform secretion col- 
lects in the inner angle of the eye and between the eyelids. This secretion is 
not abundant, but it is sometimes sufficient to unite the lids. The sense of 
hearing is probably lost as soon, or nearly as soon, as that of sight, but the 
sense of touch continues longer. The tongue is covered with a moist fur, 
unless near the close of life, when it is sometimes dry. The appetite is grad- 
ually lost, but often drinks are taken with apparent relish, even when there is 
no other evidence of consciousness. There are two symptoms pertaining to 
the digestive system which are rarely absent, and which possess great diag- 
nostic value; one is vomiting, the other constipation. In some patients irri- 
tability of stomach begins at so early a period that it is really prodromic ; 
it is rarely absent. Barrier collected the records of 80 patients with men- 
ingitis, and in 75 of these this symptom was present. It is due to the 
intimate relation existing between the stomach and brain through the gan- 
glionic system of nerves. The vomiting occurs without efi'ort, and usually 
at intervals for several days. It is a sudden ejection of the contents of 
the stomach, apparently without preceding or subsequent nausea. It con- 
trasts, therefore, with the vomiting due to an emetic, which is attended by 
distressing symptoms. With some it occurs frequently, with others not more 
than two or three times daily. Commencing in the first stages of meningitis 
or even prior to it, it occurs less often as the drowsiness becomes more pro- 
found, and finally ceases. Constipation is also present, usually from the 
commencement of the meningitis. It is one of the most constant and per- 
sistent symptoms, 'continuing through the entire sickness, unless relieved by 
medicine or unless there be a coexisting diarrhoeal aifection. Often, when 
diarrhoea precedes the meningitis, it ceases the moment the latter commences. 
The constipation in this disease is easily overcome by purgatives. Several 
writers speak of retraction of the abdomen as a sign of meningitis. A hol- 
low or sunken appearance of the abdomen, according to Golis, aids in distin- 
guishing meningitis from fever. The anterior abdominal wall approaches the 
spine, so that the pulsations of the abdominal aorta are distinctly felt. Ril- 
liet and Barthez, who have rarely observed this retraction except in cerebral 
diseases, attribute it to the state of the intestines rather than to the action 
of the abdominal muscles. 



560 MENINGITIS. 

The pulse in the first stages of meningitis is accelerated, or it is nearly 
natural during certain hours and afterward accelerated. When the disease 
has continued a few days, often not more than three or four, the pulse under- 
goes a marked change. It becomes slower and at the same time irregular. 
The irregularity usually consists in an intermittence of the pulse after each 
six or eight beats. Sometimes the force of the pulse varies, so that a feeble 
pulsation is succeeded by one of greater volume and strength. The decrease 
in the frequency of the pulse cannot fail to arrest attention. From 110 or 120 
beats per minute in the first stage of the inflammation it often descends to 
a frequency even less than that of the normal adult pulse. At an advanced 
period, as death approaches, the pulse again becomes accelerated and feeble. 

The change in respiration is as marked as that of the pulse. In the 
beginning of meningitis the breathing is in some patients moderately acceler- 
ated ; in others it is natural. AVhen the disease has continued a few days, the 
time usually varying from three or four days to more than a week, a marked 
alteration occurs in the respiratory movements. Their rhythm, like that of the 
pulse, is changed. The breathing is irregular, intermittent, and accompanied 
by sighs. The change in pulse and respiration corresponds wdth the loss of 
consciousness, and shows that the brain is becoming seriously involved. 

When the pulse and respiration undergo the changes which have been 
described, another prominent and grave cerebral symptom is sometimes pres- 
ent — to wit, convulsions. Its occurrence diminishes greatly the prospect of a 
favorable issue. The severity and extent of the convulsive movements vary 
in difierent cases. They may be partial or general. Their duration is often 
brief, but they recur three or four times through the day. They are pre- 
ceded by cephalalgia in those old enough to express their sensations, and 
often by drowsiness. Each convulsive attack ends in still greater drow- 
siness. 

With this group of symptoms another should be mentioned. I refer to 
the hydrocephalic cry. At intervals the patient, without being disturbed 
and without any change in symptoms, utters a scream or sharp cry, and 
immediately relapses into his former state. This cry is more common in the 
commencement of the meningitis than subsequently, and in many it is absent 
or is not a marked symptom. The glandular system participates in the gen- 
eral loss or derangement of function. Tears are seldom shed even when the 
child is much irritated, and the urinary secretion is diminished. The small 
amount of urine passed sustains an important relation to the progress of the 
disease and the therapeutics. 

The patient usually lingers several days after the pulse and respiration 
are changed in the manner stated. The drowsiness becomes more profound, 
the vomiting ceases as well as the convulsive attacks, and sensation and con- 
sciousness are entirely lost. But even in this state, if nutriment and stimu- 
lants be administered with regularity, the child often lives several days longer 
than appeared possible. At length increasing feebleness and rapidity of 
pulse and coldness of the face and limbs indicate the near approach of death, 
which occurs in a state of coma. 

The symptoms described above are such as we observe in ordinary 
cases of meningitis and in the order which I have indicated. But he will 
be disappointed who expects that the above description will apply to all 
cases. 

Meningitis may be so violent and rapid that both the character and suc- 
cession of symptoms are diff"erent from those which have been stated. Thus, 
I have related the case of a girl who, with no prodromic symptoms excepting 
occasional dizziness and slight headache, was taken sick on Thursday, had 
convulsions on Friday, and from this time continued either in convulsions or 



SYMPTOMS. 561 

coma till her death on Monday. Again, even in cases of the usual duration 
and anatomical character some of the most prominent symptoms upon which 
we rely for diagnosis may be lacking. The following was a case of this kind: 

Case. — On the 5th of April, 1862, I was asked to see a boy two years and 
eight months old, of healthy parentage, who during the preceding year had 
been in uniform good health, but previously had had two or three severe attacks 
of sickness. His head was unusually large, and whenever much indisposed he 
often had symptoms premonitory of convulsions, which were always, however, 
prevented. 

One night in the latter part of March his parents noticed that his sleep was 
restless, but on the following day he seemed entirely well, and the restlessness at 
night was attributed to a late and hearty supper. On succeeding nights, how- 
ever, he was restless, and Avhen questioned complained of pain in the abdomen. 
In a few days he was observed to be drooping in the day-time, and his appetite 
was not quite so good as previously. He had continued in this way about a week 
when my first visit was made. 

The abdominal pain had at this time become more constant, but was never 
severe or accompanied by moaning. When asked where he felt sick, he placed 
his hand upon the epigastrium, pressure upon which was sometimes tolerated, 
but at other times painful. The following symptoms were noted : tongue slightly 
furred, anorexia, thirst, constipation, scantiness of urine, no headache or unusual 
heat of head during any part of his sickness. He vomited at intervals from 
about the 7th to the 10th of April, when the irritability of stomach ceased and 
there was no return of this symptom. 

About April 7th the respiration was first observed to be irregular and sighing 
and the pulse intermittent. These symptoms, so tardily developed, were the 
fir.^t which indicated cerebral disease. He now lay most of the time in bed with 
eyes closed, surface commonly pallid, with occasional rose-colored spots or patches 
upon the cheek or forehead. The pupils responded to light in the usual manner 
till near the close of life, but bright lights were painful ; the last two or three 
days of his life the left pupil was more dilated than the right. He had no con- 
vulsions or any spasmodic movement, and was conscious till within a few hours 
of death : the mother states that there was unequivocal evidence of his recogni- 
tion of her on the last day of his life. He died April 17th, nearly three weeks 
after the commencement of the disease and ten days after the commencement of 
symptoms which were clearly referable to the brain. 

Autopsy. — Abdominal organs healthy, though epigastric pain had been so 
constant and prominent a symptom ; brain and its membrane somewhat injected. 
The meninges covering the base of the brain from the most prominent part of 
the pons Varolii to the first pair of nerves presented evidences of inflammation. 
There was such opacity of the pia mater in places as to conceal the brain from 
view. The anterior and middle lobes of each hemisphere were glued together 
by fibrinous exudation, and on the left side, along the fissure of Sylvius, was a 
thick deposit of the same character. The lateral ventricles contained about an 
ounce of clear serum, and about half an ounce escaped from the base of the 
brain. The foramen of Monro was considerably enlarged, and the brain-sub- 
stance surrounding the lateral ventricles was softened. 

In this case it Is seen that the prominent symptoms — and, indeed, almost 
the only marked symptom in the first stages of the disease — was pain in the 
abdomen, and yet the abdominal organs were healthy. At the very moment 
when it was highly important that a correct diagnosis should be made the 
evidences of cerebral disease were lacking. This case is therefore interesting 
on account of the variation in symptoms from those in the usual form of 
meningitis. There were no convulsions, and consciousness was retained, as 
well as vision, till near the close of life, and yet the lesions were such as are 
commonly present in meningeal inflammation. It is in such cases that a 
wrong diagnosis is frequently made, to the injury of the patient and the 
reputation of the physician. 

Occasionally meningitis may continue so long as almost to justify its 
36 



562 MENINGITIS. 

being called chronic, even when there is a large amount of exudation upon 
the pia mater. In the few cases which end favorably the symptoms abate 
gradually. I shall describe more fully the termination in speaking of Prog- 
nosis. 

Diagnosis. — It is of the utmost importance to diagnosticate meningitis 
in its first stages, since treatment to be successful must be commenced 
early. Certain writers describe at length the means of diagnosticating the 
simple from the tubercular form of the inflammation. Differential diagnosis 
is often difficult, and sometimes impossible ; but it matters little, practically, 
whether the form of the disease be ascertained. On the other hand, it is 
very important, in order that the treatment be appropriate, to diagnosticate 
the premonitory or initial stage of meningitis from certain other aff'ections 
not located within the cranium. Sometimes remittent or continued fever or 
constitutional disturbances arising from irritation in the digestive system 
simulate closely incipient meningeal disease, so that the greatest care and dis- 
crimination are required in order to make a correct diagnosis. Within a com- 
paratively recent period I have known in three different instances experienced 
physicians of this city to mistake commencing meningitis for fevers, not 
aware of the serious error they had made till the inflammation had reached a 
stage from which recovery was impossible. In order to avoid error in the 
diagnosis in the premonitory or initial stage of meningitis, the physician 
should take time to observe the physiognomy and note every symptom. 
More than one protracted visit is often required to remove doubt as to the 
exact pathological state. 

Meningitis is usually preceded, and in its commencement accompanied, 
by greater restlessness, fretfulness, intolerance of light, and a greater varia- 
tion of symptoms, than most other maladies. One familiar with the physiog- 
nomy of infancy and childhood will discover in the features indication of 
greater suffering, of more serious sickness, than is commonly present in other 
maladies which simulate this. 

Sometimes the sudden disappearance of a chronic eruption upon the scalp 
will aid in the diagnosis. This is a sign of importance, taken in connection 
with the symptoms. Headache and vomiting, symptoms of early occurrence, 
should especially arrest attention, or in absence of headache pain of a neur- 
algic character in some other part. But we may repeat that familiarity 
with the symptoms of meningitis will not protect from error if the visits of 
the physician are hasty and his examinations imperfect. When the eyes 
become affected, the respiration and circulation irregular, and especially when 
convulsive attacks begin, diagnosis is easy. In fact, an incorrect diagnosis 
would then be unpardonable ; but, unfortunately, if proper treatment have 
not been commenced till this period it will be of little service. 

Prognosis. — Meningitis is one of the most fatal maladies of early life. 
Whether the form be tubercular or not, if the initial stage have passed with- 
out proper treatment death may be considered inevitable. Tubercular men- 
ingitis, however early recognized, is rarely amenable to treatment. M. Guer- 
sant^ believes that recovery from the first stage of this form of meningitis 
is possible. " In the second stage," says he, " I have not seen one child 
recover out of a hundred, and even those who seemed to have recovered 
have either sunk afterward under a return of the same disease in its acute 
form or have died of phthisis. As to patients in whom the disease has 
reached its third, I have never seen them improve even for a moment." 
The very few reported cases which resulted favorably may have been, as 
M. Guersant has intimated in the context, cases of the non-tubercular 
form. Rilliet and Barthez believe that in a few instances tubercular meii- 

^ Did. med., t. xix. p. 403. 



TREATMENT. 563 

ingitis has been cured in its first stage, but they state also that it is apt to 
return 

The prognosis in non-tubercular meningitis is not so unfavorable, pro- 
vided that treatment be commenced at a sufficiently early period. It is now 
generally admitted that it may not infrequently be averted when threatening, 
and even arrested in its incipiency. In many such cases we cannot, from the 
nature of the disease, be certain that the diagnosis is correct. But when we 
see children relieved who present precisely those premonitory and even initial 
symptoms which occur in meningitis, we must believe that at least some of 
them would have had the genuine disease if not relieved by the measures 
employed. That in its commencement recovery is possible from non-tuber- 
cular meningitis is also obvious from the fact that a few recover even in the 
second stage, when there can be no error of diagnosis. 

Although a considerable proportion of patients with epidemic cerebro- 
spinal meningitis recover, even when the symptoms have been most grave, 
I have known only two recoveries from sporadic meningitis when it had 
reached that stage in which the functions of the brain and cranial nerves 
were impaired. One of these recovered with permanent loss of sight, the 
other with loss of hearing. Both seem to have ordinary intelligence. 
Another case has been communicated to me in which the patient, a little 
child, recovered completely, but for several months after the attack seemed 
nearly idiotic. 

Sometimes, even in the second stage of meningitis, treatment properly 
employed is attended by amelioration of symptoms. Though such improve- 
ment may serve to encourage physician and friends, it should not be the basis 
for a favorable prognosis unless it continue three or four days. 

Apparent improvement during a few hours or a considerable part of a 
day is not unusual in those who finally die. Thus, in an infant whose bow- 
els were previously confined I have known the pulse and respiration to become 
more regular and the symptoms generally improve, though only for a brief 
period, by the action of a purgative. Dr. Watson says of the advanced 
stage of this disease, it is " often attended with remissions, sometimes sud- 
den and sometimes gradual — deceitful appearances of convalescence. The 
child regains the use of its senses, recognizes those about it again, appears 
to its anxious parents to be recovering, but in a day or two it relapses into 
a state of deeper coma than before. And these fallacious symptoms of 
improvement may occur more than once." 

Most fatal cases of meningitis terminate between the third or fourth and 
the twentieth day, the duration varying according to the extent and intensity 
of the inflammation and the vigor and age of the patient. But there are 
cases in which it may continue much longer. It is surprising sometimes 
how long the patient lives when the symptoms are such that death seems 
impending. Sensation and consciousness may be extinguished, convulsions 
occur at intervals,, and the surface have acquired almost a cadaveric aspect, 
and yet the patient lives on. Rilliet and Barthez say : •' Often have we 
inscribed upon our notes death imminent^ and been astonished the next day 
to find still alive children to whom we had scarcely allowed two hours of 
life." The symptom which I have found to be the most reliable prognostic 
of the near approach of death has been a pulse gradually becoming more 
frequent and feeble, though other symptoms remain as before. This change 
in the pulse is usually very apparent during the last twenty-four hours of 
life. 

Treatment. — Such remedial measures should be prescribed during the 
premonitory stage as are calculated to relieve the fretfulness or irritability of 
temper and quiet the action of the brain, and at the same time produce a 



564 MENINGITIS. 

derivative effect from this organ. To this end the patient should be kept 
from all causes of excitement, and the bowels should be opened daily — if not 
naturally, by the use of proper medicines. A mustard foot-bath at night and 
occasionally through the day is useful, as it produces both a derivative and 
soothing effect. It will commonly produce a few hours' undisturbed rest, 
while other measures except medicines fail. If dentition be taking place and 
the gums are swollen, it has been the practice to employ the gum lancet, 
and still is with some physicians, but I for one have discarded its use for 
this purpose. Restlessness from dentition or restlessness premonitory of 
meningitis requires large doses of bromide of potassium, which will relieve 
the symptoms more effectually than the lancet. Three grains should be 
given to a child of six months, and four grains to one of ten or twelve 
months, and repeated if necessary in two to four hours. If symptoms indi- 
cate the near approach of meningitis or its incipiency, the head should be 
kept constantly cool by a cloth wrung out of ice-water — or, better, an India- 
rubber bag containing ice. Some physicians have recommended vesication 
back of the neck or ears, but it is a measure of doubtful benefit, and if 
employed at all should be restricted to the application of cantharidal collodion 
behind the ears. 

Many children who are threatened with meningitis are scrofulous. They 
have already shown symptoms of tubercular disease. They are perhaps, to 
a certain extent, emaciated, and may have been affected with a cough. If 
the premonitory symptoms in children indicate the approach of the tuber- 
cular form of meningitis, a more sustaining course of treatment is re- 
quired than in those who are robust. To such children cod-liver oil may 
be profitably given three times daily, together with the syrup of the iodide 
of iron and perhaps the bromide. They should also be taken into the open 
air with proper precautions, and every hygienic measure should be employed 
which will be likely to invigorate the system without exciting the brain. 

Loss of blood is not, in general, required during the prodromic period nor 
in the disease. Those of a strumous cachexia, or those, whether strumous or 
not, who are under the age of two years, do not, unless in very rare instances, 
require depletion by leeches, much less by venesection. There is one class 
of patients in whom the early loss of blood may perhaps be of service — 
namely, those who in a state of robust health are suddenly seized with 
inflammation, especially if the cause be insolation. Leeches may then be 
applied to the head of the patient if he be seen at an early period, but the 
majority of physicians probably wisely recommend the ice-bag in preference 
to leeching. 

Often, notwithstanding the measures employed, the patient grows worse; 
the symptoms become more continuous, others more alarming arise, and 
meningitis declares itself. Whatever the cause of the inflammation, and 
whatever modifications of treatment were required in the premonitory stage 
on account of special indications, the purpose now is to subdue the inflam- 
mation by every resource in our art which does not injure or too much pros- 
trate the system. In former days calomel was largely employed as the main 
remedy in this disease, but when administered daily it has a very depressing 
effect, and it is to be borne in mind that in meningitis the vital powders -pro- 
gressively fail on account of the loss of appetite, vomiting, etc. In tuber- 
cular meningitis depressing treatment is of course strongly contraindicated. 
Cases have occurred in which calomel was given at short intervals for 
several successive days, so as to produce a laxative effect, but, though the 
meningitis seemed to be controlled, death resulted from exhaustion or from 
some intercurrent affection due to exhaustion. Thus in one case for- 
merly related to his class by a distinguished New York professor fatal 



TREATMENT. 565 

gangrene of the mouth supervened from the mercurial treatment after the 
meningeal inflammation had apparently subsided. Although calomel during 
these last years has been properly discarded as the main remedy and its daily 
use rejected, nevertheless it is very useful as an occasional laxative in the 
more robust cases if not given too near the iodide of potassium, and it is 
especially indicated as a derivative from the head in children of four or five 
years who, previously hearty and strong, have become suddenly affected with 
meningitis, as from exposure to the sun's rays or from an injury. But I 
repeat the belief that in ordinary cases calomel should never be employed, 
except as an occasional laxative. 

The two remedies upon which we must chiefly rely are the iodide of 
potassium and the bromide of potassium or sodium. While the bromide 
quiets the restlessness, prevents convulsions, and diminishes, there is reason 
to think, to a certain extent, the hyperaemia, the iodide is useful as a sorbe- 
facient, and it probably has some control over the inflammation. The iodide 
or bromide can be given together or separately. 

The iodide should, like the bromide, be given early. If by a careful 
examination the absence of any other local disease or constitutional disease 
which might give rise to the symptoms be ascertained, and the symptoms 
indicate the meningeal disease, the iodide should be immediately prescribed. 
Obscurity often hangs over meningitis at this early stage, but it is better to 
give the iodide, even if the diagnosis be wrong and no inflammation have 
commenced, than to err on the other side, and withhold it in the initial period 
of the true disease; for it is not an injurious remedy like calomel, and to 
exert any marked eff'ect it should be given in the commencement of the 
inflammation. An infant of the age of six to twelve months should take 
two grains every two hours, and older children a proportionate dose. At the 
same time the bromide should be given in doses twice as large as that of the 
iodide if the indications for its use are present — to wit, headache, restless- 
ness, and symptoms which threaten eclampsia. The bromide is a harmless 
remedy given frequently for a limited time. With the regular and continued 
use of the iodide and occasional doses of bromide the quantity of urine is in 
most cases largely increased. If the patient's condition do not soon begin to 
improve with such treatment, there is no remedy. 

If convulsions occur, the bromide should be given every ten or fifteen 
minutes till they cease. If they be not controlled by the bromide, an injec- 
tion, ^er rectum^ of three to five grains of hydrate of chloral in a teaspoonful 
of water should be used in addition. Compresses wrung out of ice-water 
frequently applied to the head, or a bladder containing pounded ice and sep- 
arated by one thickness of muslin from the head, materially aid in reducing 
the meningeal hyperasmia. Ergot, recommended by Brown-Sequard for its 
supposed efl"ect in diminishing the hj^pera^mia in the inflammatory diseases 
of the nervous centres, may also be employed as an adjuvant in the treat- 
ment of this disease. 

In the first stage of simple meningitis the diet should be mild and in 
moderate quantity, but in the tubercular form it should from the first be of 
the most nourishing kind, consisting of beef tea, milk porridge, etc. At a 
more advanced stage in both forms of the malady the most nutritious diet 
should be allowed, but alcoholic stimulants should not be given unless near 
the close of life, when the vital powers are failing. The apartment should 
be cool and quiet. 



566 SPURIOUS HYDROCEPHALUS. 



CHAPTEE IX. 

SPUKIOUS HYDKOCEPHALUS. 

The disease known as spurious hydrocephalus might with more propriety 
be called spurious meningitis. It received its appellation at the time when 
meningitis of early life was believed to be essentially a hydrocephalus, and 
was so called. Attention was first directed to it by London physicians of the 
last generation, particularly by Drs. Gooch, Abercrombie, and Marshall Hall, 
and little can be added to their description of its symptoms. 

Anatomical Characters. — This disease, though resembling meningitis 
in certain of its phenomena, is not in its nature inflammatory, nor is it 
primary. It is the result of some malady often chronic, but occasionally 
acute, which has produced exhaustion, especially of the nervous system. 
When it commences there is usually more or less emaciation and the symp- 
toms of the primary disease are present. To this disease the lesions pertain 
which are found in other organs besides the brain. 

The state of the brain in spurious hydrocephalus is not the same in all 
cases. In some there is no appreciable anatomical alteration in this organ. 
There is no apparent diiference, either in the meninges or the brain itself, 
from the condition which we often observe in those who have died of diseases 
which do not affect the cerebro-spinal system. In such cases the pathological 
state is simply deficient innervation, or if there be a structural change in the 
minute anatomy of the brain, pathologists have not yet discovered it. 

The following case, which occurred in the Child's Hospital of this city, is 
an example of this form of spurious hydrocephalus : 

Case. — A female infant, six months old, died on the 24th day of April, 1862, 
with the following history : It was wet-nursed, fleshy, and apparently well till 
six days before death, when symptoms of gastro-intestinal inflammation were 
suddenly developed. The vomiting especially was severe, continuing forty-eight 
hours. When it ceased drowsiness supervened and continued till the close of 
life. The face during the four days of stupor was pallid and cool ; eyes partly 
open, pupils sluggish, but of equal size ; bowels rather torpid ; anterior fontanel 
depressed. When aroused the infant noticed ©"bjects for a moment, and imme- 
diately relapsed into sleep; pulse accelerated and not intermittent, the day before 
death numbering 150 ; respiration accelerated, without sighing, numbering on the 
same day 30. There were no convulsions, and death occurred quietly. The brain 
weighed twenty and a half ounces, and its appearance was perfectly healthy, 
both as regards consistence and vascularity. The amount of cerebro-spinal fluid 
in the ventricles and at the base of the brain was not notably increased. The 
stomach, small and large intestines, were vascular in streaks and patches. 

In this case the cerebral symptoms were obviously due to exhaustion 
occurring at an early period in consequence of the severity of the gastro- 
intestinal malady. 

In a majority of cases, however, of spurious hydrocephalus, according to 
my observation, there is an anatomical alteration in the state of the brain and 
meninges. This consists in passive congestion of the veins, often with tran- 
sudation of serum. At the same time, the cranial sinuses are congested, and 
are found at the post-mortem examination to contain larger and more numerous 
clots than are present in those who die of diseases which do not affect the 
encephalon. Cases might be cited as examples. The cause of this con- 



SYMPTOMS. 567 

gestion and effusion is in great measure feebleness of the circulation due to 
the general exhaustion of the patient. But there is another cause. In pro- 
tracted diseases, especially those of a diarrhoeal character, there is more or 
less wasting of the brain as well as of other parts. This naturally, by way 
of compensation, gives rise to congestion of the cerebral and meningeal veins 
and capillaries and to transudation of serum. 

The transudation commonly occurs in this malady over the superior surface 
of the brain and in the subarachnoidal space, perhaps also more or less in the 
lateral ventricles. So common is it in the last stage of infantile entero-colitis. 
the summer epidemic of cities, that this stage, which is really spurious hydro- 
cephalus, has been called the stage ^of efiusion. I shall relate in another 
place examples which show the anatomical characters of this intestinal 
disease. 

Symptoms. — Spurious hydrocephalus most frequently results from pro- 
tracted diarrhoeal complaints. It may, however, result from any disease 
which is attended by great prostration. As it ordinarily occurs, the patient 
has for days or weeks been gradually losing flesh and strength. Finally, 
drowsiness supervenes, or before the drowsiness there is sometimes a period 
of irritability. 

Marshall Hall describes two stages of spurious hydrocephalus. In the 
first, he says, " the infant becomes irritable, restless, and feverish ; the face 
flushed, the surface hot, and the pulse frequent ; there is an undue sensitive- 
ness of the nerves of feeling, and the little patient starts on being touched 
or from any sudden noise ; there are sighing and moaning during sleep, and 
screaming ; the bowels are flatulent and loose and the evacuations are mu- 
cous and disordered." The second stage he describes as that of torpor. The 
first stage often, however, does not present those prominent symptoms which 
have been described by Dr. Hall, and this stage may even be absent or not 
appreciable, especially in young infants. 

Whether or not commencing with the stage of irritability, the disease, 
if not checked, gradually increases. The child soon becomes drowsy. He 
may be aroused for a moment, but unless constantly disturbed immediately 
relapses into sleep. He is sometimes fretful when aroused, but in other 
instances is quite indifferent, observing without apparent interest objects 
employed for the purpose of amusing him. Often there are indications of 
cerebral pain or distress, as contraction of the eyebrows, etc., but many of those 
affected are too young to make known their sensations. Convulsions some- 
times occur toward the close of life, but they are not so common in this dis- 
ease as in meningitis. When they do occur they are generally partial and 
often slight. The pulse is accelerated in most patients prior to and in the 
commencement of spurious hydrocephalus. As the disease advances it 
becomes irregular and intermittent, and toward the close of life it is progress- 
ively more frequent and feeble. The respiration at first is not much dis- 
turbed, but at length it becomes irregular, like the pulse. It is feeble and 
accompanied by sighs. Occasionally, there is slight cough. The eyelids are 
partly open, the pupils no longer respond to light, and in advanced cases 
they have a bleared appearance. The diarrhoea, which in most instances 
precedes and causes this malady, continues till the stage of stupor arrives, 
when the evacuations become less frequent or cease altogether. In infants 
the stools are frequently green, in older children brown and sometimes slimy. 
The febrile heat of surface which preceded the disease, and which was pres- 
ent in its commencement, disappears ; the face and hands become cool, the 
features pallid, and the anterior fontanel, if open, is depressed. Death 
finally occurs in a state of coma, or if the disease be recognized and proper 
remedial measures employed the result may be favorable, even when the 



568 SPURIOUS HYDROCEPHALUS 

symptoms are such that if meningeal inflammation were the malady we 
would consider the case necessarily fatal. 

The following case is an example of spurious meningitis as we often meet 
it in practice : 

Case. — On the 13th day of March, 1859, I was asked to see a male child 
twenty-two months old, whose history was as follows; 

" He was well till about three weeks ago, since which time he has had diar- 
rhoea, with febrile symptoms ; pulse 162, respiration 52 ; has a slight cough, with a 
few mucous rales; resonance on percussion of chest good; is somewhat emacia- 
ted, and appears languid ; tongue moist and slightly furred Has all the incisor 
and three anterior molar teeth, and the gum is swollen over the remaining ante- 
rior molar and two canine teeth. 

" From the 14th to the 18th there was no material alteration in his symptoms, 
with the exception that the diarrhoea was partially restrained by Dover's powder 
in one-and-a-half-grain doses. On these five days the stools numbered daily 
from one to six. The pulse was uniformly frequent, varying from 124 to 156, 
and the respiration on two days, when its frequency was ascertained, numbered 
56 and 46. 

"March 19th, pulse 124; has become drowsy since yesterday, and when 
aroused is fretful. Omit Dover's poAvder. Treatment, cold applications to the 
head, mustard pediluvia. 

" Evening pulse, 136 ; eyes constantly closed and head reclining ; surface 
generally warm ; tongue dry and furred ; he vomited at first, but has not in three 
or four days. Apply cantharidal collodion behind each ear and continue the 
local treatment. 

" 20th, pulse 130 ; is constantly sleeping, and when aroused is very fretful 
and soon relapses into sleep ; no unnatural heat of head, and no dejection since 
yesterday. Treatment, a dose of castor oil, nourishing diet. 

"21st, drowsiness as before; cheeks sometimes flushed, sometimes pallid; 
pupils sensitive to light ; margins of eyelids covered with secretion. The bowels 
have been opened by the oil." 

On the 22d and 23d there was no material change in the symptoms. He was 
constantly sleeping, except for a moment when shaken. More active stimula- 
tion was now employed. Brandy was prescribed, to be given every two hours; 
beef tea and milk porridge frequently. 

On the following day, the 24th, he Avas more fretful and less drowsy. Brandy 
and beef tea were continued. 

On the 25th, with the same treatment, there was still further improvement; 
drowsiness nearly gone and less fretfulness than yesterday; rolls the head occa- 
sionally and does not appear to see distinctly ; has a slight cough ; stools nearly 
regular; pulse 100; respiration natural; surface warm, and no unnatural heat 
of head. The same treatment was continued, and he rapidly and fully 
recovered. 

This case is interesting on account of the long duration of marked drow- 
siness, which continued five days, and yet the patient recovered entirely in 
the space of two or three days under the use of brandy and beef tea. 

In May, I860, I treated a similar case. A child twenty months old had 
diarrhoea for two weeks, the stools being of a dark-brown color, thin and 
offensive. He was at first very irritable. The pulse was constantly above 
130, and the respiration was correspondingly increased. The stage of drow- 
siness finally supervened, and for two days he was constantly asleep unless 
aroused by being shaken. During the somnolent stage the pulse numbered 
140, respiration 36. . The face and extremities were cool, and he finally had 
a slight convulsion. By stimulants and nutritious diet he began imme- 
diately to improve, and was soon out of danger. 

In the following case the result was unfavorable. This case is interest- 
ing on account of the anatomical characters of the disease as disclosed by 
the post-mortem examination. It is an example of that large class of cases 



DIAGNOSIS— PROGNOSIS. 569 

in which spurious hydrocephalus is associated with congestion of the cere- 
bral vessels and serous effusion. It is exceptional, however, as regards the 
long duration of drowsiness. Ordinarily, protracted diarrhoeal maladies 
which end in passive congestion and effusion terminate fatally in three or 
four days after the drowsy period arrives : 

Case. — " Dec. 13, 1861, called to-day to a German infant eighteen months old. 
It has had diarrhoea four weeks without regular and proper medical attendance; 
stools from the first browai and thin ; during the last eight or nine days he has 
been drowsy ; when aroused opens his eyes and is very fretful, but immediately 
the upper eyelids gradually droop, and unless disturbed he remains asleep with 
his eyes partially open ; forehead warm, face cool and pallid, and limbs also 
rather cool; pulse 164, respiration 32; has had a slight cough about one Aveek, 
and slight dulness on percussion over the left infrascapular region ; de|)ression of 
inframammary region on inspiration. Treatment: Ammon. carbonat., gr. 1 
every two hours ; nourishing diet. 

" Dec. 20th, has continued drowsy since the last record ; pupils moderately 
dilated ; a thick secretion between eyelids ; right pupil considerably larger than 
the left : vision apparently lost during the last three days ; pulse over 140 ; 
respiration 44 per minute, accompanied by sighing since the 18th ; moans much 
when aw^ake ; rolls the head frequently ; during the last six days the surface 
back of the ears has been constantly sore by vesication ; takes the most nutritious 
diet with brandy. The stools remain thin and brown and number three or 
four daily. 

" From this date the diarrhoea continued, except as it was restrained by veg- 
etable astringents. The pulse continued frequent and a slight cough remained. 
There was on the 21st and 22d partial abatement of the drowsiness, but on the 
23d it was greater than ever. The body was somewhat reduced at the commence- 
ment of the cerebral symptoms, but it was now^ markedly emaciated. The pros- 
tration increased daily, and the hands were observed to tremble. The face and 
hands became more cool, while the head was warm. On the 24th partial con- 
vulsions occurred, followed by coma and death. 

" The cerebral veins and sinuses were generally congested, except in the 
anterior portion of the brain, where the appearance was normal. Between the 
brain and its membranous covering, chiefly at the vertex and the base, was an 
effusion of clear serum. The whole amount of this fluid w^as estimated at two 
ounces. On slicing the brain numerous ' puncta vasculosa ' were seen, both in 
the gray and white portions. With the exception of the congestion the sub- 
stance of the brain presented its normal appearance. No inflammatory lesions 
were present. We were not permitted to examine the condition of the intes- 
tines." 

Diagnosis. — The only disease with which spurious hydrocephalus is 
liable to be confounded is meningitis. The points of differential diagnosis 
are the history of the case, especially the antecedent diarrhoea or other 
exhausting ailment, evidence of prostration when the cerebral malady com- 
menced, depression of the anterior fontanel if it be open, and the cool face 
and extremities. 

Prognosis. — If the pathological state of the brain be simple exhaustion, 
the disease can often be arrested by judicious treatment. If an incorrect 
diagnosis be made and the treatment employed be that appropriate for 
meningitis, which it so closely simulates, death is almost inevitable. If 
transudation of serum have occurred, unless slight, the result is usually 
unfavorable whatever may be the treatment. This disease in childhood is 
more easily managed than in infancy, but is less frequent. The prognosis is 
better in the cool months than during the heat of summer. It is more favor- 
able if the child be over than if under the age of one year. The occurrence 
of an irregular and intermittent pulse, of respiration accompanied by sighs, 
of inequality in the pupils or their sluggish movements, with increasing 
stupor, indicates an unfavorable issue. The cure of the primary disease, 



570 ECLAMPSIA. 

with tlie pulse and respiration still natural or accelerated, without change of 
rhythm, pupils sensitive to light, drowsiness from which the patient is easily 
aroused to a state of entire consciousness, render recovery probable with 
proper medication and alimentation. 

Treatment. — The indications of treatment are twofold : first, to remove 
the primary pathological state which is the cause of the spurious hydro- 
cephalus ; and, secondly, to cure the latter. The first is important, since 
the successful treatment of a disease requires the removal of the cause. 
The measures employed for this purpose are pointed out in our description 
of the diarrhoeal and other maladies which produce spurious hydrocephalus. 

We may here say that, as spurious hydrocephalus is due in a very large 
proportion of cases to the exhausting eff'ect of long-continued diarrhoea, 
astringents, especially subnitrate of bismuth, and alkalies are required in a 
majority of cases in the stage of irritability, and sometimes also opiates. 

Active sustaining measures are indicated. Exhausted nervous power, 
as well as passive cerebral congestion, requires these. The diet should be 
highly nutritious, comprising such substances as milk and beef juice, and 
should be given frequently. Brandy is required at shoi't intervals. Dr. 
Gooch was in the habit of giving the aromatic spirits of ammonia, properly 
diluted, as a quick and active stimulant. Six or eight drops may be given 
in sweetened water to a child one year old, and repeated every hour in cases 
of urgency. If by proper treatment of the cause and by the use of stimu- 
lants and nutritious food the patients do not within a few hours become less 
stupid and more conscious, there is that degree of nervous exhaustion or of 
serous transudation from the engorged cerebral veins which will render 
death probable. In some cases it is proper to produce moderate vesication 
behind the ears. 



CHAPTER X. 

ECLAMPSIA. 

The term " eclampsia " is used in a more restricted sense by some writers 
than by others. It is employed in the following pages to designate those 
convulsive seizures, clonic in their character, sometimes general, sometimes 
partial, which affect the external muscles, and are due to some exciting cause. 
It consists in rapid, forcible, and involuntary muscular contraction alternating 
with relaxation. It is distinguished from chorea in the fact that the latter 
is a more permanent state, and is characterized by muscular movements which 
are partially under the control of the will and are not so violent. The symp- 
toms of eclampsia closely resemble those of epilepsy, but these diseases are 
distinguished from each other by characters which will be mentioned here- 
after. 

Eclampsia occurs in a great variety of diseases, some of which are located 
in the cerebro-spinal system, some in other parts of the body, and some are 
constitutional. It may also be produced by temporary derangements of sys- 
tem not sufiiciently severe to be considered diseases, and by powerful mental 
impressions, those of an emotional nature affecting the delicate and sensitive 
nervous system of the child. Pathologists recognize three different forms of 
eclampsia. The term essential or idiopathic is used when the convulsions 
have no appreciable anatomical character ; that is, when there is no appa- 



CA USES. 571 

rent pathological state in the brain or elsewhere which gives rise to the 
attack. For example, if a child die in convulsions from fright, and all the 
organs, including the brain, are found in their normal state, the eclampsia is 
called idiopathic or essential. If the cause be disease of the brain or spinal 
cord, it is termed symptomatic. If eclampsia arise from local disease else- 
where than in the cerebro-spinal axis, as from pneumonia, the term sympa- 
thetic is employed. This is in the main a good division, but eclampsia may 
be at the same time sympathetic and symptomatic, as when it occurs in con- 
sequence of congestion of brain which is induced by severe and frequent 
paroxysms of whooping cough. 

Causes. — Eclampsia occurs at any period of infancy and childhood, but 
it is much more rare after the period of six or seven years than previously. 
Some children are more liable to it than others. It is produced in one 
by an agency which in another has no appreciable effect. There are some, 
generally those of an impressible nervous system, who are seized with con- 
vulsions whenever there is any slight derangement in the digestive or other 
organs. Eclampsia is frequent in certain families. Thus, Bouchut mentions 
a family of ten persons all of whom had convulsions in their infancy. One 
of them married and had ten children, who, with one exception, had con- 
vulsions. 

The exciting causes of eclampsia are too numerous to be mentioned in 
full. It is a symptom in nearly all cerebral diseases. It is produced in the 
nursling by changes in the milk with which it is nourished. These changes 
are usually due to violent emotions of the mother, as anger, fright, and grief, 
to the use of acescent or indigestible food, or to derangement, temporary or 
permanent, in her health. Thus, in a case related to me the catamenia so 
affected the milk that the infant was seized with eclampsia at each monthly 
period. In childhood the most common cause of clonic convulsions is the 
presence of some irritant in the primse vise. All kinds of fruit, even the 
mildest, may produce eclampsia, especially when eaten unripe or taken in 
undue quantity. I have known an infant to be seized with convulsions from 
eating strawberries, which parents usually regard as harmless, and one of 
the most violent and protracted cases of eclampsia which I have witnessed 
occurred in a child over the age of six years from swallowing, in considerable 
quantity, the parenchymatous portion of an orange. Constipation, worms, 
dysentery, intussusception, and painful dentition are also causes which are 
located in the digestive apparatus. Inflammation in some part of the respi- 
ratory apparatus is a not infrequent cause. Thus, eclampsia occurs occasion- 
ally in severe coryza, in consequence, according to some, of the proximity of 
the inflamed surface to the brain and the consequent afflux of blood to this 
organ. It is a common complication also of pertussis and pneumonia. It 
occurs often at the commencement of two of the eruptive fevers — namely, 
smallpox and scarlet fever, and in the course of the latter disease. 

Violent emotions of the child may also cause eclampsia. Bouchut relates 
the case of a girl five years old who was corrected before her companions, 
and was so affected by anger that convulsions ensued. Residence in close 
and overheated apartments or in streets where the air is loaded with offensive 
vapors and is stifling, is a predisposing cause, so that there is a larger propor- 
tion of deaths from convulsions in the cities than in the country. 

In young children burns, even when not very severe, are liable to termi- 
nate suddenly in eclampsia, succeeded by coma and death. Urinary calculi, 
both renal and vesical, may produce the same result. 

Such are the more common causes of eclampsia. It is seen that they 
are of two kinds, predisposing and exciting. An excitable or impressible 
state of the nervous system constitutes the chief predisposition to the dis- 



572 ECLAMPSIA. 

ease. Plethora, or its opposite state anaemia, increases the liability to an 
attack. 

Premonitory Stage. — In the majority of cases there are prodromic 
symptoms which the experienced and careful physician can detect so as to 
forewarn friends. The child is perhaps more or less drowsy, and, when dis- 
turbed, fretful. The eyes often have a wild or unnatural appearance ; occa- 
sionally they are fixed for a moment on an object, and yet apparently with- 
out noticing it. The sleep is disturbed; in some there is unusual heat of 
head, and, if old enough, complaint of headache. At times, especially if the 
primary disease be febrile or inflammatory, there is incoherence of thought 
or expression, or even actual delirium. In some children when eclampsia is 
threatening the thumbs are seen to be carried across the palms. I have 
observed this especially during the convulsive cough of pertussis. A very 
important prognostic symptom is sudden starting or twitching of the limbs. 
This shows that the nervous system is profoundly impressed, and but slight 
additional excitation is required to develop eclampsia. This sudden starting 
not infrequently precedes the attack several hours and gives sufficient fore- 
warning. 

The prodromic symptoms are often disregarded by friends who do not 
understand their significance. Even physicians, in the haste of their visits, 
m many instances do not notice them. The symptoms which precede symp- 
tomatic and sympathetic eclampsia are, moreover, blended with those of the 
primary affection, and hence another reason why they are frequently over- 
looked. When the convulsions are about to commence the child generally 
lies quiet ; the eyes are open and fixed. If spoken to or shaken he takes no 
notice and does not speak. The direction of the eyes is then changed ; often 
they are turned up ; occasionally there is strabismus. The face may be pale 
or flushed, and sometimes, especially in cerebral diseases, the features present 
patches or streaks of a flushed appearance, while around them the natural 
color is preserved. Immediately before the spasmodic movements the child 
sometimes utters a piercing scream, which is probably involuntary, though it 
seems like a supplication for help. The duration of the prodromic stage is 
very different in diflerent cases. It may last from a few minutes to several 
hours, or even more than a day. 

Symptoms. — Eclampsia is general or partial. If general., the muscles of 
the face, eyes, eyelids, and of all the limbs are in a state of rapid involuntary 
contraction, alternating with relaxation. The features lose their natural 
expression and are distorted ; the mouth is drawn out of shape, often to one 
side, by the violent muscular actipn ; the teeth are pressed together by tonic 
contraction of the masseters, and may be violently struck together, so as to 
lacerate the tongue if it protrude, or are ground upon each other. Unless 
the attack be of short duration, frothy saliva, perhaps tinged with blood from 
the injured tongue, collects between the lips. The eyelids are usually open, 
and in severe cases the eyes are turned so that the pupils are lost under the 
upper eyelids, or the muscles of the eyes are involved in the spasmodic move- 
ment so that the eyeballs are forcibly drawn from side to side. Occasionally 
strabismus occurs. While the features are thus distorted the head is strongly 
retracted or is turned to one side ; the forearms are alternately pronated and 
supinated ; the thumbs and fingers are convulsively flexed, so that the thumbs 
lie across the palm« and are covered by the fingers ; the great toe is adducted, 
the other toes flexed ; and the toes, as well as legs, participate more or less in 
the spasmodic movements. 

In general convulsions, consciousness is usually lost. The head is hot 
previously to and during the attack — at least in the first part of it — -and the 
face flushed. In exceptional cases, especially in sympathetic eclampsia, the 



SYMPTOMS. 573 

head is cool and the face pallid. The pulse is somewhat accelerated, as well 
as the respiration, and the latter is rendered irregular if the respiratory mus- 
cles, especially those of the larynx, are involved, as they generally are. The 
sphincters are relaxed during the convulsive attack, so that in many cases the 
urine and stools are passed involuntarily. 

Partial eclampsia is more common than the general form ; it occurs in 
the muscles of the face, including those of the eye, of the face and of one 
or both upper extremities, or of the face and the extremities on one side. 
The spasmodic movements may be even limited to the muscles of the eye, 
and they often occur only in these muscles and those of the face. Rarely, 
if ever, does eclampsia aifect the legs without affecting also the muscles of 
the arms and face. In partial convulsive attacks sensation and consciousness 
are in some patients not entirely lost, but in others they are not manifested 
if present. 

The duration of an attack of eclampsia varies in diff"erent cases from a 
few minutes to several hours, with an average of not more than from five to 
fifteen minutes. The mos^ements do not often continue longer than three or 
four hours in the severest cases. They are sometimes said to last a much 
longer time, even for days, but in these cases there are intermissions. Violent 
attacks are usually short. 

When the convulsion ends favorably the spasmodic movements become 
less and less strong, and finally cease. The child then takes a deep inspira- 
tion, after which it lies quiet, and the respiration remains regular or mod- 
erately accelerated. Some fully recover in a few minutes if the eclampsia 
have been light and the cause transient, and seem to experience no incon- 
venience except soreness of the muscles and fatigue. Others soon recover 
consciousness, and their temperature, respiration, and circulation become 
natural, but they remain dull for a time, their minds are bewildered, and 
they are perhaps unable to speak. In a few hours these untoward symptoms 
pass away. In essential, and in a large proportion of cases of sympathetic, 
eclampsia, if properly treated and if the cause be recognized and removed, 
there is no recurrence of the convulsion ; with others it is diff"erent. In many 
cases, especially of symptomatic eclampsia, and of sympathetic in which the 
cause is grave and persistent, the convulsions return after a variable period 
of a few minutes or a few hours. Six or eight or more convulsions may 
occur within twenty-four hours. Rarely they occur several times daily for 
several consecutive days, but severe convulsions, repeated at short intervals 
for twenty-four or forty-eight hours, usually end in fatal congestion of the 
brain or serous eff'usion. I once attended an infant about six months old 
who had from four to twelve convulsions daily for eleven days, caused prob- 
ably by a vesical calculus, as there was dysuria and at times bloody urine. 
Some days after the convulsions were controlled, while we were deferring 
exploration of the bladder, death occurred suddenly, and an autopsy was not 
permitted. This case will be detailed elsewhere. Bouchut has witnessed a 
case of whooping cough in which there were daily convulsions for eighteen days. 

In severe eclampsia the respiration is so embarrassed and circulation so 
retarded that congestion of various organs results. This passive congestion 
in the respiratory organs is indicated by moist rales in the larynx and bron- 
chial tubes ; occurring in the brain, it is indicated by profound stupor. It 
has already been stated that death may occur from the cerebral congestion, 
which, continuing, is apt to end in eff'usion of serum or extravasation of blood. 
In these cases the convulsive movements cease, but there is no return of con- 
sciousness. The child lies quiet, as if in sleep, with pupils not readily acted 
on by light, and often somewhat dilated ; gradually the limbs grow cool and 
the pulse feeble, and fatal coma supervenes. 



574 ECLAMPSIA. 

Death does not ordinarily occur from one attack. There are several at 
intervals, during which the stupor is gradually becoming more and more pro- 
found, till finally total loss of consciousness and sensation results, terminating 
in death. Apnoea may occur in the first attack, ending life abruptly and 
unexpectedly, but in other instances it does not result till after several seiz- 
ures, when at length one more violent than the others interrupts the respira- 
tory function and causes death. 

Occasionally when life is preserved there is some permanent ill-eifect of 
eclampsia. Bouchut says : " The origin of certain permanent contractions 
which bring on deviation of the head or other parts, retraction of the limb, 
paralysis, etc., must be referred to the convulsions of the muscles, I have 
seen several children in whom torticollis had no other cause. The drooping 
of the upper eyelid, strabismus, irregularity of the mouth, severe contractions 
of the limbs, often depend on this influence. These accidents are consequences 
of essential as well as of symptomatic convulsions." 

Anatomical Characters. — The morbid anatomy pertaining to eclamp- 
sia is in most cases twofold : first, the pathological states which precede and 
cause the convulsive movements ; secondly, those which result from them. 
We have seen that in sympathetic eclampsia the diseases which sustain a 
causal relation are very numerous : some are constitutional, others local, 
and the latter may have their seat in almost any part of the economy distinct 
from the cerebro-spinal axis. In some cases of sympathetic eclampsia the 
immediate cause is too active a circulation, a state of hyperaemia of the cere- 
bral vessels. 

It has already been stated that this hyperaemia may be diagnosticated in 
young infants in whom the anterior fontanel is open. Such infants, seized 
with acute inflammation of one of the mucous surfaces, often present a full 
and rapid pulse and a convex and forcibly pulsating fontanel before the 
eclampsia begins. In other cases of sympathetic eclampsia the primary 
disease induces passive congestion of the brain, and this in turn gives rise to 
convulsions. Eclampsia occurring during the paroxysms of whooping cough 
aff"ords an example. 

In some cases of sympathetic eclampsia the convulsive movements are pro- 
duced by the primary disease acting directly on the nervous system through 
the medium of the nerves, without causing any appreciable alteration in the 
state of the cerebro-spinal axis. Thus, Barrier relates three fatal cases of 
convulsions occurring in pneumonia, in none of which was there anything 
abnormal in the condition of the brain or its membranes. 

The pathological state preceding symptomatic eclampsia diff"ers in difl'er- 
ent cases, since convulsions occur in almost every disease of the brain and 
its membranes. The immediate cause of this form of eclampsia may be 
active or passive cerebral congestion, with or without eff"usion : it may be 
compression of the brain from various causes ; it may be a deficiency as well 
as excess of the cerebro-spinal fluid. 

The congestion resulting from eclampsia may give rise to extravasation 
of blood and the formation of a clot. If this accident occur, there is often 
paralysis affecting more or less of one side permanently, or gradually dis- 
appearing. 

It may be difiicult to decide whether the cerebral congestion precedes the 
eclampsia or is its result; but in those cases in which it precedes and ope- 
rates as a cause it is no doubt increased during the convulsive period. The 
spasmodic muscular action, by rendering respiration irregular and imperfect, 
also leads to congestion of the lungs, and sometimes of other organs. 

Diagnosis. — The only disease which resembles eclampsia is epilepsy, but 
the diagnosis can ordinarily be made by recollecting the following facts : 



PROGXOSIS. 575 

Eclampsia is most common in infancy. If it occur after the age of three 
years there is some manifest exciting cause which renders the child seriously 
sick independently of the convulsions, and prior also to their occurrence. 
But in epilepsy first attacks are very often mild, the petit mal of writers : in 
other cases they are tolerably severe from the first ; but, whether mild or 
severe, they occurwith no previous or coexisting sickness and with little or 
no warning. 

The symptoms in eclampsia and epilepsy are identical, except as the causes 
of eclampsia produce certain concomitant symptoms, and there is every reason 
to believe that the spasmodic muscular movements proceed from an irritation 
of the same portion of the cerebro-spinal axis — to wit, the medulla oblongata. 
Writers like Niemeyer have given reasons for the belief that spasmodic 
muscular movements are produced by functional disturbance of this part of 
the nervous centre. I may state the following, to which I am not aware that 
any one has alluded : If the exposed medulla of an acephalous monster be 
pressed or pinched convulsions like those of eclampsia and epilepsy result. 
These two diseases, therefore, have a close resemblance anatomically and 
clinically, but by attention to the above facts they can ordinarily be dis- 
tinguished from each other. 

In most cases of eclampsia the child has fever or other pronounced symp- 
toms of the primary disease, which suffice for diagnosis : but we have fre- 
quently examined epileptics in the Bureau for the Relief of the Out-door 
Poor whose first attacks were evidently produced by some exciting cause, 
and were eclamptic. One attack of clonic convulsions predisposes to 
another, and therefore eclampsia, if the attack be repeated a few times, not 
infrequently ends in epilepsy. The convulsions, which at first are produced by 
an obvious cause, now occur without apparent cause. 

It is often difficult to ascertain the form of eclampsia, whether essential, 
symptomatic, or sympathetic — in other words, to determine the cause — till 
after the convulsions cease. This is especially true when, as is frequently 
the case, the physician is not summoned till the convulsive movements begin, 
and it is necessary that he should act promptly, with but little knowledge of 
the child's previous history. If there be an obvious antecedent disease, as 
whooping cough or meningitis, the cause is apparent ; but if the previous 
health have been good or but slightly disturbed, it may be necessary to make 
more than one visit or examination in order to ascertain the seat and charac- 
ter of the cause. In the majority of cases of convulsions occurring suddenly 
in a state of previous good health the cause is seated in the intestines, but 
sudden and unexpected attacks may be due to the commencement of some 
inflammatory affection, as pneumonia, or of a febrile disease, as smallpox. 
Unless the eclampsia be speedily fatal, the physician, if he examine carefully, 
will in most cases soon be able to ascertain the nature of the cause and diag- 
nosticate the form of the disease. 

Prognosis. — Symptomatic eclampsia is always serious. If it occur in 
the course of a cerebral disease, it indicates the approach of death, but if at 
its commencement the patient may recover. Its recurrence, whatever the 
cerebral disease, is usually prognostic of death. 

In idiopathic or essential convulsions the prognosis depends on the sever- 
ity of the attack and on the age, strength, and previous condition of the 
child. If there be predisposing or co-operating causes, as a nervous or excit- 
able temperament or dentition, the prognosis is less favorable than when such 
causes are absent. 

In sympathetic eclampsia the prognosis varies greatly, according to the 
nature of the primary disease and often according to the stage of that disease. 
If convulsions occur at the commencement of an eruptive fever, they gener- 



576 ECLAMPSIA. 

ally subside without untoward symptoms and the fever pursues a favorable 
course. Eclampsia after the appearance of the eruption is premonitory of a 
fatal result. I have not yet known a patient with scarlet fever recover who 
had convulsions after the rash had covered the body, and experienced physi- 
cians of this city tell me that their observations correspond with mine. Dr. 
J. F. Meigs, however, relates one favorable case. If the cause of the eclampsia 
be located in or upon the mucous surfaces, a majority recover with judicious 
treatment. In convulsions consequent on pneumonia or a burn more die than 
recover. 

The prognosis in eclampsia is more favorable if the parallelism of the eyes 
be retained, the pupils remain sensitive to light, and consciousness soon return. 
A fatal termination may be predicted if, after the convulsion, the child remain 
stupid, without any evidence of returning consciousness, and the pupils do 
not respond to light. 

Treatment. — Fortunately, inasmuch as the physician is often required 
to treat eclampsia in ignorance of the cause, the same measures are demanded 
to a considerable extent in all cases, whether the form be essential, symp- 
tomatic, or sympathetic. As early as possible in the attack the feet should 
be placed in hot water to which mustard is added, or if it can be procured 
with little delay a general warm bath may be used in its place. This has a 
soothing effect upon the nervous system and promotes muscular relaxation, 
while it also produces derivation of blood from the cerebro-spinal axis. It is 
therefore useful, especiall}^ in those cases in which active or passive conges- 
tion precedes the eclampsia : it is also useful as a preventive of passive con- 
gestion and consequent oedema of the brain, lungs, and other organs, which 
are the most serious results of eclampsia. It should be continued from six 
to fifteen or twenty minutes, according to the severity and duration of the 
attack ; at the same time cold applications should be made to the head until 
its temperature, which is usually increased, is reduced. The application of 
cloths placed upon ice or frequently wrung out of cold water is the most 
convenient and ready mode of employing this agent. Cold thus employed 
acts promptly in contracting the vessels of the brain and meninges and dimin- 
ishing the cerebral congestion. It tends, therefore, to remove one of the 
chief dangers. 

Cold applications are also useful for reducing an elevated temperature 
if it be present. In most cases of eclampsia, if the temperature reach 103°, 
the necessity for its reduction is urgent, and the cold cloths or India-rubber 
bag containing ice should be applied not only upon the head, but also along 
the sides of the face, and sometimes over the great vessels of the neck. 

Since a large proportion of convulsive attacks originate in the condition of 
the intestines, either solely or in part, it is advisable to prescribe an aperient 
unless there be previous diarrhoea. 

The common enema of soap and water will usually produce a free and 
speedy evacuation, and will sometimes disclose the cause of the eclampsia in 
the expulsion of seeds or other indigestible substances or scybala. A cathartic 
is also often required, especially if the enema fail to produce sufficient evacu- 
ations. In those that are robust, and especially in those beyond the age of 
two or three years, calomel is an excellent purgative, is easily given, and is 
prompt in its action. If the symptoms indicate intestinal inflammation, the 
milder purgatives, as castor oil, are preferable, as they also are in young or 
feeble children. If the recent ingesta of the patient consisted of fruit or of 
substances of an indigestible character, an emetic is appropriate ; a teaspoon- 
ful of the syrup of ipecacuanha, repeated if necessary in fifteen or twenty 
minutes, may be given to a young child, or this syrup mixed with the syrup 
scillae compositus to one older and more robust. Aside from the ejection of 



TREATMENT. bll 

the offending substance which it produces, an emetic has some effect in con- 
trolling the convulsive movements. But the cases are rare in which emetics 
are indicated. 

In addition to the local measures mentioned above, and measures calcu- 
lated to relieve the digestive canal of any offending substance, a safe medici- 
nal agent which will act promptly in relieving the convulsions is urgently 
demanded, since eclampsia, if severe and protracted, involves great danger. 
Fortunately, such agents have been lately introduced into therapeutics — 
namely, the bromide of potassium or sodium and hydrate of chloral. These 
agents, while they are effectual, are safe, and therefore their use has sup- 
planted that of the antispasmodics, asafoetida, valerian, lavender, and chloro- 
form, formerly employed ; not one of which, except chloroform, exerts any 
direct controlling influence over the convulsions, and chloroform is a danger- 
ous remedy unless used sparingly. 

The bromide of potassium, which I prefer, should be given every ten 
minutes, dissolved in cold water, till the convulsions cease, in doses of four 
grains to a child of one year, and of five to eight grains to a child of two or 
three years. When the convulsions cease the interval between the doses 
should be lengthened. In one instance in my practice an infant of eighteen 
months was suddenly seized with eclampsia, and the mother, in her fright 
mistaking the "directions, gave thirty grains of bromide at one dose. Two 
hours afterward, when I was able to attend, I found that the convulsions had 
ceased at once and that the patient was playful. Such cases show the innoc- 
uousness of a large dose of the bromide and the safety in administering the 
medicinal dose often. 

In severe cases the bromide does not always act with sufficient prompt- 
ness and power. The hydrate of chloral should then be emploj^ed, given by 
the mouth or dissolved in two or three drachms of water, and given with 
a small glass or gutta-percha syringe per .rectum. If used in sufficient 
quantity per rectum^ and retained by pressure with a napkin, it is quickly 
absorbed, and will usually in about fifteen or twenty minutes control the 
eclampsia. For a child of one year I employ about two grains, and for one 
of four years four grains, given by the mouth, or double this quantity given 
per rectum. With the use of the measures indicated above eclampsia is, in 
my practice, much more amenable to treatment than in former years. Unless 
the cause be such that recovery is impossible from the very nature of the 
case, the convulsions will soon cease with these measures. It is interesting 
to observe the effect of the chloral enema. In from five to ten minutes 
the convulsive movements cease in the muscles of the face, a moment later 
in those of the arms, and lastly in those of the lower extremities. 

But additional treatment may be required, according to the pathological 
state which has brought on the eclampsia. If it be an eruptive fever, as 
scarlatina, and the eruption have receded, active revulsive measures, as hot 
mustard baths, are required ; if in dysentery or other internal inflammation, 
the flaxseed and mustard poultice should be applied over the parts affected. 

In those dangerous cases in which symptoms of cerebral congestion con- 
tinue after the eclampsia ceases additional treatment is required. The child 
remains drowsy, does not speak or apparently suffer in any way, and the 
pupils act less readily than in health. If this condition remain after the 
lapse of a few hours there is probably serous effusion. All attacks of 
eclampsia, unless the mildest, are followed by a period of drowsiness, but 
the persistence of it, with symptoms which indicate hyperaemia, with per- 
haps effusion within the cranium, calls for the employment of additional 
measures. Vesication by cantharidal collodion should then be produced 
behind the ears, mild revulsives be applied to the extremities, the head kept 
37 



578 EPILEPSY. 

cool, the bowels open, and in certain cases a diuretic like iodide of potassium 
may be advantageously employed. The utmost care should be enjoined in 
reference to the hygienic management of those who are subject to eclampsia. 
The diet should be nutritious but bland, and all causes of excitement be 
studiously avoided. 



CHAPTER XI. 
EPILEPSY. 

Epilepsy is a paroxysmal disease. The paroxysms are manifested by 
impairment or loss of consciousness, and in fully-developed and typical cases 
also by convulsive movements of more or fewer of the voluntary muscles. 
Epilepsy is a neurosis or functional affection of the nervous system, not due, 
therefore, to any appreciable structural change in the brain or spine. The 
convulsions are tonic or clonic, or most frequently both, the tonic preceding 
the clonic. 

Etiology. — In a large proportion of cases we are able to discover both 
predisposing and exciting causes of the first attack, but one convulsion pro- 
duces such a change in the nervous system that the liability to another 
attack is increased. Hence after the epileptic habit is established after one 
or a few attacks, convulsions usually occur without any apparent exciting 
cause; and if such a cause be discovered, it is evidently insufficient without 
the presence of a strong predisposition. 

Predisposing Causes. — Prominent among these is a neurotic inherit- 
ance. Echiverria, whose observations were made in the epileptic wards on 
Blackwell's Island, states that 28 per cent, of the 300 epileptic patients 
examined by himself presented evidences of inheritance. In Reynolds's 
cases the number was 31 per cent., and in 1218 cases examined by Gowers 
the number who presented evidences of an inherited predisposition was 429, 
or 35 per cent. The morbid state in the parent which gives rise to an inher- 
ited predisposition to epilepsy in the child is most frequently epilepsy or 
insanity. Less frequently, according to Gowers, the parental disease is 
chorea, hysteria, or a spinal malady. Inherited predisposition is said to be 
more frequently from the mother than from the father. The occurrence of 
epilepsy in a brother or sister renders it probable that the patient has inher- 
ited a predisposition, although we may be unable to trace it to either parent 
or any of the ancestry. The evidence of a strong inherited predisposition is 
sometimes apparent by the number of near relatives affected by the same dis- 
ease. Thus, Gowers states that in one instance the patient's mother, aunt, 
two uncles, and a cousin were epileptic, and in another instance fourteen near 
relatives had epilepsy. 

Age. — Statistics relating to the age at which epilepsy begins have been 
published by Haase, Gowers, and others. These show that three-fourths of 
the cases begin under the age of twenty years, one-fourth under the age of 
ten years, and about one-eighth under the age of three years. 

Exciting Causes. — Immediate or exciting causes of epilepsy are usu- 
ally most apparent in cases which begin during infancy or childhood. The 
history of a large number of epileptic children has been ascertained during 
the last twenty years in the children's class in the Out-door Department at 
Bellevue, and very frequently we were informed that at the first attack the 
child was feverish or constipated or had some acute ailment, which served as 



EXCITING CAUSES. 579 

the exciting cause. Often the first convulsions were attributed to dentition, 
but we now know that most of the cases which are attributed by the parents 
to teething are due to other causes, as constipation, diarrhoea, the presence of 
indigestible or irritating ingesta in the intestines, rachitis, or some acute 
infectious or inflammatory disease. If the child have a succession of dis- 
eases giving rise to convulsions, they may be sufficient to establish the epi- 
leptic habit, even when there is no apparent predisposition to epilepsy. 
Thus. Gowers relates the case of a child of healthy parentage and without 
any inherited predisposition, that had a fit at the age of six months, attrib- 
uted to teething ; another at the age of two years, from scarlet fever ; 
another at four and a half years, from measles ; and another at sixteen and 
a half years, from a carbuncle. These repeated convulsive attacks ended in 
a permanent epilepsy. 

Mental Emotion. — Fright or great excitement, from whatever cause, is the 
most common and potent of the immediate causes of epilepsy. It produced 
the first convulsive attack in 157 of Gowers's cases, or in more than one-third 
of those in which an exciting cause was assigned. This cause is operative 
chiefly in the periods of childhood and youth, when the emotions are strong, 
and in females more frequently than in males. Among the enumerated 
causes of the mental excitement, authors mention fire-alarms, burglaries, thun- 
der-storms, and pretended ghosts. Gowers. states that a soldier on sentry-duty 
at night was so frightened by some white goats that appeared suddenly on the 
wall of an adjacent cemetery that he was seized with convulsions and became 
an epileptic. Sudden and profound emotion has sometimes been the exciting 
cause of chorea, and in other instances of epilepsy, in cases which I have 
observed, in one instance in an emotional child, the sight of the corpse of a 
favorite uncle producing this result. In another instance a physician of my 
acquaintance, in treating a female child with scarlatinous nephritis, ordered a 
warm bath. The next day, visiting the patient and learning that his direc- 
tions had not been heeded, he prepared a bath and in a rude manner plunged 
the child in it. She was much frightened, and immediately had a severe con- 
vulsion. The scarlatinous ursemia probably predisposed to the attack, but 
the fright was the exciting cause. She has been a confirmed epileptic from 
that day, the fits being frequent and severe. Treatment employed at inter- 
vals during the last ten or twelve years has had but little effect in controlling 
them. Gowers states that in an aggregate of 76 cases in which epilepsy 
resulted from fright the convulsion occurred immediately in 28, within a few 
hours in 16 others, after the first day, but within seven days, in 19, and at a 
later period than one week in 13. 

Protracted cares or anxieties, which prevented the needed mental rest, 
have also in some instances been the only assignable cause of epilepsy, but 
this cause is less frequent in childhood than in adult life. 

Traumatism. — Usually the injury received is upon the head, either from 
a fall or a blow, by which the patient is stunned or rendered unconscious for 
a time. The convulsion may occur immediately or not until the lapse of a 
day or more. Traumatism is ordinarily attended by much mental excitement, 
and this has its influence in producing the convulsive attack. 

Among the less frequent but occasional causes of epilepsy in infancy and 
childhood we may mention inherited syphilis, intestinal worms, scarlet fever, 
measles, pneumonia, rheumatism, exposure to a high degree of heat, especi- 
ally to the sun's rays, masturbation, renal disease, and peripheral causes hav- 
ing a reflex action, as phimosis, cicatrices, and a decayed tooth. When these 
causes are removed, the clonic convulsions which they have produced may 
cease, but in other instances they continue, the epileptic habit having been 
established. 



580 EPILEPSY. 

Symptoms. — Two forms of epilepsy have long been recognized and 
described in standard treatises — the mild and severe forms, the epilepsia 
mitior and epilepsia gravior ; or, in the French language, le petit mal and 
le grand mal. As the terms imply, this classification is based on the differ- 
ence in the severity of the attacks. 

Minor Attacks. — These are characterized by momentary dizziness and 
usually loss of consciousness. The patient has a bewildered look ; his 
speech is interrupted, even in the middle of a sentence, and his work, 
whatever it may be, is also interrupted, so that whatever he is holding- 
drops from his hands. His pallor, bewildered look, and strange actions 
attract attention, but in a moment he resumes his work and his speech. 
When the attack is over he may be at once in his ordinary mental and 
physical condition, and seem quite well, but he does not have a clear recol- 
lection of what has happened. Some patients after the attack ceases 
remain for a time in a drowsy state and without full perception, or their 
speech and acts may be passionate and violent until they regain their normal 
state. 

Major Attacks. — These begin abruptly with strong tonic contraction of 
the muscles, which causes rotation of the head to one side, a fixed lateral, 
and sometimes upward, deviation of the eyes, and a constrained and awk- 
ward position of the extremities. The facial, thoracic, and abdominal mus- 
cles participate, causing distorted features and embarrassment of respiration. 
The face, at first pallid, soon becomes livid, the pupils are dilated, the con- 
junctiva insensitive, and the eyes are in some patients open, but in others 
closed. The cyanosis deepens and the surface becomes very livid. In a 
moment the muscles begin to vibrate and undergo alternate relaxations and 
contractions. The second stage, or that of clonic convulsions, begins. The 
head, face, body, and limbs are violently jerked, saliva tinged with blood 
flows from the mouth, and sometimes the urine and feces are expelled. The 
patient presents a striking and shocking spectacle, which gave rise in olden 
times to the belief of demoniacal possession. Presently the muscular relaxa- 
tions become longer, more air is inhaled, and the blueness, which was intense, 
begins to abate. The muscular contractions, though as severe as at first, are 
less frequent, and finally cease, and the patient, weak and unconscious, sleeps 
quietly but soundly. Occasionally, instead of a simultaneous commencement 
of the attack in all parts of the body, it begins in one region and extends to 
others on the same side, and then, diminishing on this side, it begins on the 
opposite side. In this form of epilepsy the patient may not lose conscious- 
ness until late in the attack, so that he at first is aware of his condition, and 
the convulsions may be clonic from the first. 

Aura. — Certain patients exhibit symptoms which are premonitory of the 
attack some hours before its occurrence. One of these is the sudden jerk- 
ing of certain muscles, as of the arms or legs. This usually occurs when 
the patient is awake, but it may occur when he is asleep or is falling asleep. 
Another occasional premonitory symptom is persistent dizziness preceding 
the attack some hours or even days. A ravenous appetite, a stifling sensa- 
tion in the chest, as if from want of air, numbness, cephalalgia, impairment of 
sight, the vision of red fiery sparks (Aretasus), and irritability of temper 
occasionally precede the attacks, so as to forewarn the patient and friends. 
Bootius in 1649 described a premonitory symptom which was observed in 
rare instances, but which was thought to justify the recognition of a variety 
of the disease that was designated epilepsia cursiva. The patient ran a short 
distance and then was seized with the convulsion. Another similar precur- 
sory symptom immediately preceding the attack is mentioned by writers. The 
patient, if walking, even if entering his home, turns around, retraces his steps, 



SY3IPT0MS. 581 

and falls down in tlie fit. The premonitory symptoms described above, which 
enable the epileptic, with the aid of his friends, to reach a place of safety 
before the attack begins, occur in a small proportion of cases. 

Many epileptic fits begin with an aura — a term first employed by Pelops, 
the predecessor and teacher of G-alen, to indicate a sensation which com- 
mences in some part away from the brain and ascends toward it. In olden 
times the aura was supposed to be a vapor, which traversed the vessels to the 
brain and caused the attack. It is now known that it ordinarily has a cen- 
tral origin, is due to commencing functional disturbance of the brain, and is 
a part of the fit. It is true that the immediate application of a ligature or 
tight band above the aura, which arrests its ascension to the brain, will often 
prevent the fit, but Odier, Brown-Sequard, and Gowers have shown that this 
occurs in epilepsy due to cerebral tumors even more frequently than in epi- 
lepsy which has no appreciable anatomical cause. Therefore, this fact of the 
arrest of the convulsion by ligation above the aura cannot be employed as an 
argument in support of the theory of the peripheral origin of the attacks. 

The statistics of Romberg. Sieveking, and Gowers show that an aura occurs 
in about half the cases. The aura may begin in any peripheral portion of 
the system, in any of the organs of the special senses, and in many of the 
internal organs. By knowing from what portion of the brain the nerve 
arises which supplies the part that is the seat of the aura, we are enabled to 
state which of the divisions of the brain is probably so affected as to produce 
epilepsy. 

The aura varies greatly in its character as well as location. It is a sen- 
sation of pain, numbness, burning or tingling, or instead of being sensory it 
may be wholly or chiefly motor, as cramps, jerking, twitching of a certain mus- 
cle or group of muscles occurring. Sometimes the aura is at the same time 
both sensory and motor. The sensory aura commonly ascends, as we have 
already stated, toward the head, but it occasionally descends a limb, and 
when it reaches a certain point the convulsion begins. The aura often occurs 
in one side of the face, tongue, or trunk, or in one limb. In other instances 
it is bilateral or general, commencing simultaneously in corresponding limbs 
of the two sides. Aurge in the trunk, and not in the viscera, occur almost 
entirely in the back, along the spine, and are known as the spinal aurae. 
General aurae are sometimes characterized by faintness, malaise, or power- 
lessness, or a general tremor or a general sensation of coldness or of heat. 
Visceral auree occur for the most part in viscera supplied by the pneumogas- 
tric. The most common of these aurae is the epigastric, a pain or a sensation 
in the epigastrium, vaguely described as a "heat," "coldness," "trembling," 
a " twisting " or " winding up." The epigastric aura may be a little above 
or below or to the left of the epigastrium. In some cases the aura is located 
in the chest or throat. A sensation of suffocation or tingling or burning, or 
an indescribable feeling, is experienced in the chest or throat immediately 
before the attack begins. The patient perhaps presses upon his chest or 
throat with his hands and immediately becomes convulsed. The heart also 
derives its innervation from the pneumogastric, and the aura is sometimes 
referred to this organ. In some patients the cardiac region is the seat of 
a vague sensation variously described, or the aura may be manifested by 
increased action or palpitation, with perhaps more or less dyspnoea. Of the 
cephalic aurae, vertigo is perhaps the most common, attended in some by rota- 
tion of the head and occasionally of the body. In certain epileptics there is 
the sensation of rotation without actual movement, and in some instances 
objects seem to move. Cephalic aurae in a considerable number of instances 
consist of headache or a sensation in the head described as heaviness, pres- 
sure, coldness, burning, etc. 



582 EPILEPSY. 

In certain cases the aurse are entirely emotional, having usually the form 
of fear, which is sometimes so great that extreme terror is depicted on the 
countenance, and yet there may be no remembrance of it after the convulsion 
is over. In a considerable number of instances the aurge are manifested in the 
organs of the special senses, and consist in an aberration of their functions. 
The olfactory aura is usually an unpleasant smell, as of sulphur, putrid mat- 
ter, pus, decaying animal substances. The gustatory aura is a bitter, sour, 
metallic, or nauseous taste. The ocular aura is an unusual sensation in the 
eye — diplopia, an apparent change in the size of objects viewed, sudden 
blindness, or the perception of unusual or striking objects, as a flash, sparks, 
colored lights, or persons or things not present, sometimes quiet, sometimes 
in motion. The auditory sensations occurring as aurse are sounds of many 
kinds — of music, of bells, thunder, a whistle, the wind, an explosion or any 
other startling sound. It is seen that the aur^e, although having a central 
origin, occur in almost every part of the system, remote from as well as near 
the brain, and are of many different kinds. 

In some epileptics a harsh scream or groan announces the commencement 
of the fit, but in children, according to my observations, it rarely occurs. It 
is apparently produced by a spasm of the laryngeal muscles, which causes 
narrowing of the passage through the larynx, and a spasmodic contraction 
of the thoracic and abdominal muscles, which causes a rapid and forcible 
expiration. The patient is unconscious of the scream, or he may be conscious 
of it, but unable to prevent it. 

In the fit, when of ordinary severity, consciousness is early lost, and it 
does not return until the somnolence which follows the attack has abated ; but 
in the mild disease, the petit mal, the patient, though confused, often retains 
consciousness during the attack. In the grand mal the attack begins with 
a tonic spasm of the muscles, causing rotation of the head and deviation of 
the eyes to one side. Sometimes there is rotation of the entire body, so that 
the patient turns around one or more times before he falls. The position of 
the limbs during the tonic spasm varies. Commonly the arms are slightly 
abducted, the forearms flexed to a right angle, the hands flexed at the wrists, 
the fingers flexed on the hands, but extended at the other joints, and the 
thumb is pressed upon the palm or fore finger. The legs are ordinarily 
extended, but the legs as well as arms may assume different positions. 

Clonic convulsion, or the second stage of the attack, supervenes in a few 
seconds or after two or three minutes. The tonic spasm relaxes gradually, 
and the clonic spasm supervenes gradually. The clonic convulsion or alternate 
contraction and relaxation, rapidly succeeding each other, occur in the muscles 
of the face, tongue, palate, and larynx, as well as in the muscles of trunk 
and extremities. The tongue is frequently bitten, both in the tonic and 
clonic spasms, so that the blood oozes, and, mixed with frothy saliva, exudes 
from the mouth. The pupils are dilated during the attack, and they do not 
contract by light. As soon as consciousness begins to return, the pupils 
begin to contract and respond to light. Exceptionally, at the close of the 
fit the pupils alternately contract or dilate at intervals of one or two seconds, 
and, as already stated, the conjunctiva loses its sensitiveness, so that it can 
be touched without producing reflex action of the orbicularis. Relaxation 
of the sphincters also often occurs during the fit, so that fecal and urinary 
evacuations take place. 

The pulse may be normal or rather feeble in the beginning of the attack, 
but its frequency, and sometimes its fulness, increase during the muscular 
spasms. The features, usually pallid, but sometimes flushed at the beginning 
of the attack, become congested and even cyanotic in less than a minute. 
The congested and livid features present an alarming appearance, and fre- 



ANATOMICAL CHARACTERS. 583 

quently the general surface is bathed in perspiration before the attack ends. 
Ophthahnoscopic examination of the eyes during the convulsion is difficult, 
but during the cyanotic stage the retinal vessels have been seen presenting 
an engorged and dusky appearance. Growers states that in one instance, in 
which fits occurred in rapid succession during several days, he observed con- 
gestion of the discs with slight oedema, which disappeared after the attacks 
ceased. In the intervals of the paroxysms nothing has been noticed in the 
appearance of the eyes which throws light on the nature of the disease. 
The duration of the second stage of an epileptic fit or that of clonic spasms 
varies from a minute or two to a considerably longer time. When it ceases 
the patient passes into a sleep or deep stupor, which continues a quarter of 
an hour or longer. If aroused from the stupor he complains of severe head- 
ache, and this continues often for hours after the stupor ceases. 

Languor and muscular weakness are common after the fit, and they grad- 
ually pass ofi". When, as occasionally happens, paralysis occurs after the fit 
and continues for weeks or permanently, organic cerebral disease is present, 
either preceding and causing the fit or resulting from it. If no paralysis or 
cerebral symptoms have preceded a fit, and it is followed by paralysis of one 
or more of the extremities, it is highly probable that intracranial hemorrhage 
has occurred during the attack. Todd, Hughlings Jackson, and others 
attribute the muscular weakness following an epileptic attack " to exhaus- 
tion of part of the brain by the excessive action," but protracted or per- 
manent loss of muscular power in an epileptic having good general health 
indicates organic disease in the brain. 

The above description relates to epilepsy as it ordinarily occurs, but there 
are many cases which vary from the typical form. Tonic convulsions may 
occur without the clonic, and clonic convulsions without the tonic, and the 
convulsions, instead of being general, may be limited to a limb or to one 
region of the system. Of 155 cases of minor epilepsy, Gowers states that 
in 45 the disease was indicated by momentary attacks of unconsciousness, 
faintness, or sleepiness; in 25 by dizziness; in 17 by sudden jerking of 
head, trunk, or limbs ; in 17 by loss or aberration of sight ; in 8 by a mental 
state, as sudden and extreme fright ; and in the remaining 42 by sensations 
of various kinds or momentary rigidity or by tremors or twitching occurring 
in some part of the system. Automatic movements sometimes occur during 
the stage of unconsciousness which succeeds the attack, and the attack may 
be so light that it is not noticed by the bystanders. Gowers relates several 
such instances. Some patients begin to undress themselves, whatever the 
surroundings ; others make the motions of walking up stairs, although no 
stairs are present; some put in their pockets any near object, without regard 
to its nature or ownership. Trousseau states that an architect during the 
state of unconsciousness ran from plank to plank on the scaifold where he 
was at work, shouting his own name. One of Gowers's patients during the 
unconscious state laughed and sang ; another threw her infant down stairs ; 
a girl of twenty kissed every object within her reach ; and a man struck his 
friend a severe blow. Many supposed criminal acts have been perpetrated by 
unconscious epileptics, for which they have been severely punished. 

Anatomical Characters — No information has been obtained in regard 
to the etiology and nature of idiopathic epilepsy by a study of its anatomical 
characters. If the patient have died in the attack, intense venous congestion 
is observed of the cerebro-spinal axis as well as of other parts, but in recent 
eases nothing else abnormal has been detected in the brain or elsewhere. The 
thickening and opacity of the cerebral meninges sometimes observed in 
chronic cases, and the induration of the pes hippocampi described by 
Meynert, are now believed to be results of the repeated attacks, and not 



584 EPILEPSY. 

their cause. Structural change in the brain in idiopathic epilepsy, if there 
be such, which sustains a causal relation to the attacks, has thus far eluded 
detection by the microscope. 

Pathology. — Epileptic attacks are believed by neuropathists to be due 
to a sudden and exaggerated functional activity of nerve-cells in some part 
of the brain. The theory at present accepted is that these cells generate a 
nerve-force which, transmitted along the nerves, stimulates the muscles to 
spasmodic contraction. In regard to the part of the brain in which these 
overacting cells reside, we may state that Brown-Sequard and Kussmaul 
demonstrated that convulsions may be produced by irritating the pons and 
medulla when every other part of the encephalon lying above these is 
removed. Convulsions can also be produced in acranial monsters, as I have 
stated above, by irritating the exposed medulla and pons. Nothnagel has also 
shown that there is a " convulsive centre " in the medulla oblongata. On 
the other hand, injuries of the convolutions more frequently cause convul- 
sions than do those of any other part of the brain, and Wilks and others 
have taught that in ordinary epilepsy the part of the brain which is most 
frequently in fault, so as to cause convulsions, is the superficial portion or 
the convolutions. Still, the exaggerated production of nerve-force which 
causes the convulsions may be at a greater depth than the convolutions, 
even when the attacks are due to traumatism, since, as Burdon-Sanderson has 
shown, nerve-cells more deeply seated than the convolutions may be stim- 
ulated to increased functional activity by injuries of the superficial regions. 
Therefore, Nothnagel, aware of the fact that injuries of the cortex often 
cause convulsions, states that he sees no reason to modify his opinion that 
the exaggerated production of nerve-force which causes the convulsions is in 
the " convulsive centre in the medulla oblongata." The above observations 
seem to indicate that epileptic attacks do in some instances originate in the 
convolutions or hemispheres, and in others in the medulla. 

Becently, Gowers and others have endeavored to determine in what part 
of the brain the nerve-force resides which causes the convulsions, by study- 
ing the aurae. Since the aurae have a central origin and are the first mani- 
festation of the exaggerated action of the nerve-cells, the attempt is made to 
determine the location of these cells by observing the nature and the seat 
of the aurae. Gowers says that one-fifth of the aurae pertain to the special 
senses, and the nerve-centres of these senses " are certainly situated within 
the hemispheres, above the pons." Therefore, the inference is inevitable 
that in these cases the discharge of nerve-force which stimulates the muscles 
to spasmodic action is in the hemispheres. Moreover, a fit that is preceded 
by an emotional or mental aura, we infer, originates from the nerve-cells of 
the hemispheres which are the seat of the mind. The theory is therefore 
plausible and apparently sustained by clinical observations, that in at least 
some instances the epileptic centre in the brain is in the hemispheres, though 
it may in other instances be at the base of the brain — in the medulla or 
pons. 

What occurs in the brain to produce the phenomena of epilepsy ? It 
is the belief of many specialists in nervous diseases that epilepsy results 
from suddenly developed cerebral anaemia produced by spasmodic contraction 
of the arterioles. It is also the belief of some that the primary discharge 
of nerve-force occurs in the medulla at the vaso-motor centre, and that this 
is followed by spasm of the arterioles in the hemispheres, by which conscious- 
ness is lost. That cerebral anaemia is present is inferred from the fact that 
the features are usually pallid when the attack commences. But in many 
instances, especially in epilepsy of a mild type, no pallor or other sign of 
peripheral anaemia is present, and in such cases there is no evidence what- 



DIAGNOSIS. 585 

ever of cerebral anaemia. Besides, as Gowers has forcibly stated, pallor of 
the features does not necessarily indicate cerebral anaemia, any more than 
flushing of the face indicates cerebral hypersemia. In experiments on frogs 
irritation of the brain causes contraction of the peripheral arterioles. Prob- 
ably in the same manner, says Gowers, the contraction of the peripheral 
arterioles and the pallor result from the irritation of the brain occurring in 
the first stage of the fit. That cerebral ansemia occurs in the attack, and 
that it sustains a causal relation to the phenomena of epilepsy, are assump- 
tions destitute of proof. 

As to the pathology of epilepsy, we have said or have intimated that it 
is the belief of the majority of those who from large clinical experience are 
most competent to express an opinion that the epileptic attacks are produced 
by a hyperactivity of nerve-cells in the gray matter in some part of the 
brain, and an increased discharge of nerve-force, which stimulates the mus- 
cles to spasmodic action. The spinal cord and the nerves are implicated as 
carriers of this nerve-force. Farther than this we are unable to express any 
theory in the present state of our knowledge. 

Diagnosis. — In a considerable number of instances nocturnal epilepsy 
is entirely overlooked. Some patients awaken at the beginning of the 
attack, and have subsequently a vague recollection of its occurrence. Others 
are aware of the fit by subsequent signs or symptoms, as a bitten tongue, 
blood on the bed-clothes, a swollen and ecchymotic face, conjunctival extrav- 
asation, and perhaps evacuations in the bed. In children nocturnal epi- 
lepsy is more likely to be detected than in adults, since they are more closely 
watched. Gowers states that he has known it to occur twenty years with- 
out being suspected. In mild epilepsy the symptoms may escape the notice 
of friends, and when observed by the patients and friends their import is often 
misunderstood. Those suffering from prtif mal are in many instances sup- 
posed to have attacks of faintness. The differential diagnosis between epileptic 
vertigo and syncopal faintness is made by the fact that in the latter the pre- 
vious health has usually been poor, the action of the heart feeble, and there 
is some exciting cause of the sudden cardiac weakness ; whereas in epileptic 
vertigo such conditions do not, as a rule, exist. In epileptic vertigo there is 
no premonition except the aura, which is momentary, and recovery or return 
to the normal state is rapid. Syncope, on the other hand, begins and ends 
in a more gradual manner. 

The symptoms of eclampsia and epilepsy are identical as regards the 
convulsive movements. We designate by the term " eclampsia " those 
attacks which are due to local or general causes, which do not recur when 
these causes are removed, and the occurrence of which, whatever the causes, 
is limited to a brief period. But, as we have seen, one attack of convul- 
sions predisposes to another, and one or more convulsive fits that are eclamp- 
tic frequently establish the convulsive habit, so that epilepsy results. In a 
large proportion of the cases of eclampsia the convulsions have a reflex 
origin. They are produced by causes located at a distance from the brain 
and affecting the nervous centres, causing convulsions through the medium 
of the nerves. Painful and swollen gums in dentition, constipation, irrita- 
ting ingesta, intestinal worms, scarlet fever, nephritis with albuminuria, are 
among the common causes of eclampsia. In recent convulsions, when such 
causes are present, the diagnosis of eclampsia will be proper in the great 
majority of instances, and the attacks will cease and not recur when the 
apparent causes are removed. Gowers regards rickets as a common cause of 
eclampsia in young children, and remarks that when this diathetic state is 
cured by " cod-liver oil and steel wine " the convulsions no longer occur; 
but if proper treatment be not employed, if the rickets continue, and with 



586 EPILEPSY. 

it the frequent convulsive attacks, the epileptic habit may be established and 
epilepsy continue during the reniainder of life. 

Prognosis. — Epilepsy is rarely fatal, although the symptoms are very 
appalling to one who has not previously v^itnessed an attack. Asphyxia has 
occasionally occurred by the patients falling in water during the fit. Even 
little depth of water with the face downward is sufficient to cause fatal 
obstruction to inspiration. Therefore, not a few epileptics die by drowning. 
If the patient roll upon the face during the fit, or vomit, he may be asphyxia- 
ted by the bed-clothes or by the entrance of particles of food in the larynx. 

The spontaneous cessation of the epileptic fits and spontaneous cure of 
epilepsy rarely occur, since each attack tends more strongly to establish the 
epileptic habit. Fortunately, since the therapeutic uses of the bromides have 
become known epilepsy has frequently been cured. In infancy and childhood, 
in the majority of instances, epilepsy is rendered milder, so that the fits occur 
at longer intervals, even if entire cure be not effected. Moreover, the pros- 
pect of curing epilepsy is better in children than in adults, in accordance 
with the law that the shorter its duration and the fewer the attacks which 
have already occurred the more amenable it is to treatment. Epilepsy in 
which several days intervene between the attacks is, as might be expected, 
more likely to be benefited by treatment than when the attacks are frequent. 
If the mind be not perceptibly impaired, if the fits are uniformly severe, 
instead of some being severe and others mild, if they occur only during sleep 
or only during wakefulness, and if hemiplegia be absent, the prognosis is 
better than when the reverse is the case. In ordinary cases of epilepsy in 
childhood the attacks immediately become less frequent by the bromide 
treatment. If a sufficient amount of the bromide be administered three 
times daily, months often elapse before a recurrence of the attack ; but if 
the remedy be discontinued after six months or a year in the belief that the 
patient is cured, a recurrence of the disease is probable. A patient cannot 
be pronounced cured until three years have elapsed without any symptoms. 

Treatment. — No mode of treating epilepsy which will effect an imme- 
diate cure has yet been discovered, nor is it probable that such success of 
treatment will ever be obtained. Cure is effected by treatment which dimin- 
ishes the hyperactivity of the nerve-cells that are in fault, and prevents the 
exaggerated production of nerve-force. 3Iedicines designed to effect this 
object must be given daily for a prolonged period, since their use for a few 
days or weeks does not suffice to produce the desired change in the nerve- 
centre. 

Since the bromides have come into general use in the treatment of nervous 
diseases, the first place is universally accorded to them among the remedies 
for epilepsy. The bromides of potassium, sodium, ammonium, and lithium 
have probably nearly the same effect, but the potassium and sodium bromides 
are usually prescribed. No advantage results from the use of bromine or 
hydrobromic acid, even if it were safe and convenient, for it becomes a 
bromide as soon as it enters the alkaline blood (Gowers). Ail the bromides 
produce acne, but this can be prevented to a considerable extent by the 
simultaneous use of arsenic in small doses. The bromide should be given 
daily for weeks or months in the smallest dose which is found to arrest the 
fits or, if it do not entirely arrest them, produces the most decided effect upon 
them. If the fit occur at a certain hour; one daily dose, administered 
previously, may suffice to prevent it, but usually it occurs irregularly, and a 
morning and evening dose or three daily doses are required. Bromism, 
indicated by a weak pulse, cold extremities, and mental and physical dulness, 
has never, according to my observations, seriously interfered with the treat- 
ment. During my long connection with the children's class of the Bureau 



TREATMENT. 587 

for the Relief of the Out-door Poor at Bellevue almost every week new cases 
of epilepsy have been presented for treatment, and it has seldom been neces- 
sary to discontinue the use of the bromide on account, of bromism. A girl 
had her first attack of clonic convulsions at the age of four months. When 
she reached the age of three years and a few months she began to have 
attacks of the j^etit mal, manifested by pallor and an epigastric aura, followed 
by sleep lasting one or two hours. These attacks occurred at irregular inter- 
vals. In her fourth year she had measles and scarlet fever. In her seventh 
year she came under observation. A strict milk diet was ordered, and she 
took one teaspoonful in the morning and two at night of the following mix- 
ture : 

R. Sodii bromidi, .^iiiss; 

Aquffi, o^^'j- Misce. 

This treatment was continued with scarcely an interruption during her 
seventh, eighth, and ninth years, with complete cure of the disease and with 
bromism only on one occasion. Gowers, writing of adults, remarks that few 
patients can take more than one and a half drachms of the bromide daily 
without bromism. But, according to my observations, children can take lar- 
ger proportionate doses than this without injury. Although prescribing the 
bromide of potassium daily for children of all ages during many years, I 
have seldom observed any ill effects which were clearly attributable to its use 
except the occurrence of acne. Bromism soon disappears when the dose of 
the bromide is diminished or its use is discontinued. In general, this medi- 
cine should be given twice or three times daily during as long a period as 
two years after the last paroxysm, without diminishing the dose which is 
found sufficient to cure the disease ; and, to make sure of a cure, it should 
be employed a third year in a gradually diminishing dose. In the case 
related above the patient, a girl then at the age of nine years, had taken the 
bromide of sodium two years in two doses of thirteen and twenty-six grains 
with complete arrest of the attacks, when she had symptoms of bromism. 
The bromide was discontinued, and she remained well for some weeks, but 
finally she stated that the furniture at times seemed to move. Half the 
previous dose was now employed for a month or two, when it was discon- 
tinued, and she has remained well without medicine during the six or eight 
months which have since elapsed. In slight bromism during the first and 
second years of treatment it is usually better, I think, to diminish the dose 
of the bromide ; but not to discontinue its use, and at the same time to 
employ a vegetable tonic with alcohol. In great cerebral depression due to 
the bromide, it is probably better to entirely discontinue its use for a time, 
even if convulsions occur. 

Occasionally, the bromide employed alone does not cure epilepsy. It may 
then be given in combination with another drug which is believed to exert 
some controlling influence upon the disease, as digitalis, belladonna, cannabis 
indica, or zinc. These remedies were prescribed with apparent benefit in at 
least certain instances before the bromides came into use. Digitalis has been 
employed as a remed}^ for epilepsy since Parkinson recommended it in 1640. 
It is not very efficient when used alone, but in some instances when given 
with the bromide it evidently increases the curative power of this agent. 
Gowers says : '• In many cases attacks which continued on bromide only 
ceased entirely on bromide and digitalis." He observed good results from 
the use of this combination, especially in epileptics who had cardiac disease, 
as dilatation, valvular insufficiency, hypertrophy, and a too rapid pulse. 
Benefit also occurred in some instances in which the heart's action was nor- 
mal, as in the following case : Jesse , aged twelve years, was Avhen an 



588 EPILEPSY. 

infant rachitic, backward in teething and the use of his limbs. He had the 
first epileptic fit at the age of sixteen months. The attacks occurred at 
intervals of one week, and were preceded by a visual aura, a red ball of fire, 
that approached the eye. Fifteen grains of the bromide of ammonium, with 
five minims of the tincture of belladonna, were prescribed, to be given twice, 
and subsequently three times, daily. With this treatment the intervals 
between the fits were lengthened to one month, but they still occurred after 
six months' treatment. Five minims of the tincture of digitalis were then 
substituted for the belladonna, and no fit occurred for eleven months. On 
diminishing the dose of digitalis, one fit occurred, but on resuming its use in 
five-minim doses seven months elapsed without an attack. A girl of eighteen 
years had a convulsion at the age of two years, another at seven years, and 
confirmed epilepsy since her tenth year. The attacks occurred about every 
second day, without an aura. The bromide alone and bromide with bella- 
donna were employed, with slight diminution in the frequency of the attacks. 
Digitalis with the bromide was then employed. Immediately the fits were 
reduced to four, then to two, in the month, and then four months elapsed 
without a fit. A girl aged eleven years, greatly frightened by a thunder- 
storm, began to have nocturnal epileptic attacks. At the age of fourteen 
years, when treatment was commenced, the attacks occurred nearly every 
night. One scruple of the bromide of potassium and ten minims of tincture 
of belladonna reduced the attacks to one in ten days. Then the treatment 
was changed to two scruples of bromide of ammonium and five minims of 
tincture of digitalis, taken once daily at night, and two months passed with- 
out an attack, when she was lost sight of. These cases, to which more might 
be added, show that digitalis combined with the bromide increases the efficacy 
of the latter in certain cases. 

Belladonna has been employed in the treatment of epilepsy during the 
last two centuries. It was recommended by Mardorf in 1691, and by Hufe- 
land, Stoll, and others in the eighteenth century. Its proper use is in com- 
bination with one of the bromides when the latter is inadequate to arrest the 
attacks. Used alone, it does not cure epilepsy, though occasionally it renders 
the attacks less frequent. But Glowers relates cases which show that it 
increases the efficiency of the bromides in certain cases when combined with 
them. It is believed to first stimulate and then depress the functions of the 
nervous system, acting not upon one part only, but upon various parts of 
brain and spinal cord, aff"ecting their functional activity. To show the effect 
of the combination of belladonna with the bromide, Gowers relates the case 
of a boy in whom epilepsy commenced at the age of thirteen years without 
known cause. The attacks began usually in the morning without an aura, 
at intervals of three weeks. Fifteen grains of the bromide administered 
night and morning reduced the attacks to one a month. After three months 
of treatment twenty grains of the bromide and five minims of tincture of 
belladonna were given three times daily, and two months elapsed without an 
attack, when two occurred. Subsequently, he took the same medicine four- 
teen months without an attack, when treatment was discontinued. Six months 
later he was still well. Other cases have been related in which belladonna, 
combined with the bromide, produced a more decided curative action than 
the bromide employed alone ; but in some instances, as we have seen, when 
these two agents fail to cure this result is accomplished by the bromide and 
digitalis. The liquor atropias, one minim of which contains ^^-^ of a grain 
of atropine, may be used in place of the tincture of belladonna. 

Stramonium, cannabis indica, and gelsemium sempervirens have been pre- 
scribed with some apparent benefit in certain instances, but it is the common 
belief with those who have employed them that they are no more efficacious 



TEEATMEXT. 589 

than digitalis and belladonna, and they seldom if ever cure the disease when 
used alone. When employed with the bromide, good results have followed, 
but the improvement has probably been due almost entirely to the bromide. 

Zinc has been recommended in the treatment of epilepsy for more than a 
century by good observers. In experiments on animals it has been found to 
diminish reflex action, and it exerts some controlling effect on the functions 
of the hemispheres and the medulla oblongata. It diminishes the frequency 
of the epileptic attacks in many patients, but not usually so certainly as the 
bromides, or to such an extent. In exceptional instances zinc prevents the 
epileptic attacks to a greater extent than the bromide, especially when they 
present the hysteroid form. The oxide, lactate, and citrate are commonly pre- 
scribed, and a child of eight years can take from one to two grains three times 
daily. It should be given after the meals, since it sometimes irritates the 
stomach and causes nausea. It is believed by Gowers to be slowly converted 
into the chloride in the stomach. He relates the case of an adult epileptic 
who took five grains of the oxide of zinc morning and evening, and had no 
attack during the five months in which he was under observation. A girl of 
eight years having inherited epilepsy, after four months of treatment with 
the bromide was still having two fits each week. Oxide of zinc in doses of 
three grains was ordered, and in two months the fits ceased. Nine months 
elapsed with only one attack, when the patient was lost sight of. Growers 
also relates the following case, showing that the addition of the zinc to the 
bromide sometimes plainly increases the efficiency of the latter : A boy of 
eleven months, belonging to an epileptic family, had a fit at the age of eleven 
months. At the age of fourteen years, when he was presented for treatment, 
the convulsions occurred every two weeks. One scruple of bromide of 
ammonium administered three times daily caused some improvement, as did 
the bromide with digitalis, but the disease was not cured until the zinc was 
employed with the bromide. In obstinate cases, therefore, zinc is sometimes 
useful as an adjuvant to the bromide. 

Opium, or its alkaloid morphia, has been long employed in the treatment 
of epilepsy, but its use has now given place, for the most part, to that of 
other remedies. Occasionally, especially in the hysteroid forms of epilepsy, 
morphia given at the commencement of the warning has apparently pre- 
vented the fit. 

The eff'ect of iron in epilepsy is equivocal and uncertain. Brown- 
Sequard and Jackson discountenance its use, as they think it increases the 
frequency of the attacks. Gowers sa^^s that he has given iron to several 
hundred epileptics, and that it only rarely increases the severity of the fits. 
In most instances it produces no ill eff'ect, and it sometimes improves the 
general health. He states that occasionally bromide with iron arrests the 
attacks when the bromide alone has little eff'ect. 

A. considerable number of remedies which we have not mentioned have 
been employed, but they have been for the most part discarded by recent 
observers, either because they have been found to be inert or have been use- 
ful only in rare cases, and less useful than other remedies. 

According to my observation, the treatment which has been found ade- 
quate to arrest the fits should be continued at least two years after the last 
paroxysm, being omitted for a few days or its quantity reduced if symptoms 
of bromism occur. Even after a cure for two years occasional symptoms of 
the petit mal may occur, so that it will be necessary to resume the use of the 
medicine in smaller doses. 

Hygienic Treoiment. — It is necessary that an epileptic child should lead a 
quiet and regular life, free from excitement and all perturbating influences. 
The diet should be plain and easily digested. In some instances a diet con- 



590 INTERNAL CONVULSIONS. 

sisting almost entirely of milk has seemed to be a very important remedial 
measure. 



CHAPTER XII. 

INTERNAL CONVULSIONS (SPASM OF THE GLOTTIS; LARYN- 
GISMUS STRIDULUS). 

Young children are liable to temporary suspension of respiration, induced 
by violent emotions, especially by anger. In the midst of their excitement, 
while they are crying or screaming, their breath is suddenly held, as if from 
tonic spasm of the respiratory muscles. In a few seconds respiration returns 
and is natural. There is no stridulous inspiration or other unusual sound, 
and there is no apparent ill-effect, unless occasionally a degree of languor. 
External convulsions, which seem to be threatening, seldom occur, and when 
they do are ordinarily mild. Some writers consider dentition the predispos- 
ing cause of this arrest of respiration by inducing a sensitive state of the 
nervous system. Such an effect of dentition is possible, but certainly many 
infants are affected in this manner before the age of dentition. 

A much more serious state, and one which is recognized as a true disease, 
is that variously designated by writers as internal convulsions, spasm of the 
glottis, child-crowing, laryngismus stridulus, etc. Manifest difficulties attend 
the investigation of the pathological state in this disease. There can be little 
doubt that it is not precisely the same in all cases. That there is, during the 
paroxysms, tonic or clonic spasm of more or fewer of the respiratory muscles 
is inferred not only from the symptoms pertaining to the respiratory appa- 
ratus, but from the fact that in severe cases spasms of the external muscles, 
as those of the limbs and face, often occur. Usually, also, the movements 
of the eyeballs indicate spasmodic contractions of the motor muscles of the 
eyes. The fact of spasmodic muscular action in parts that are visible justi- 
fies the belief that it occurs in other parts which are concealed from view, 
especially as the characteri.stic symptoms cannot be readily explained except 
on this supposition. Trousseau says: "Internal convulsions consist, then, 
principally in a spasm of the diaphragm and of the respiratory muscles of 
the abdomen and chest ; but it occurs also that the muscles pertaining to the 
larynx are affected with spasm at the same time with these." Rilliet and 
Barthez conclude from the symptoms that the " heart is not always a stran- 
ger to this internal convulsion, which perhaps prolongs itself even to the 
intestines." The muscles of the pharynx appear to be involved in some 
cases, as well as those of respiration, rendering deglutition difficult. In one 
form of internal convulsions — namely, that which is principally referred to 
by writers — there is not complete arrest of respiration, but the inspirations 
during the paroxysms are difficult and are attended by a stridulous noise. 
Again, the respiration may cease entirely, but when it commences it is strid- 
ulous and difficult during a few inspirations. In still another form of the 
disease respiration ceases, but there is no symptom or sign indicative of glot- 
tic spasm or of an obstacle to the ingress of air ; the inspirations which suc- 
ceed the paroxysm are easy and noiseless. It has been suggested that in 
these cases there is paralysis rather than spasmodic contraction of the respi- 
ratory muscles ; but the symptoms may be explained in accordance with the 
commonly accepted opinion — namely, that there is spasm of the diaphragm 
and perhaps of certain muscles of the chest and abdomen, while the laryn- 



CAUSES. 59 1 

geal muscles are not aifected. M. Herard, indeed, who has written one of 
the best monographs on internal convulsions, describes three forms of the 
disease according to the supposed location of the spasm — namely, laryngeal, 
diaphragmatic, and another which consists of a blending of the two. 

Internal convulsions are not frequent in this country ; they are rare in 
France, more frequent in Germany, and quite common in England. They 
occur, with few exceptions, before the age of two years. Dr. West observed 
31 cases under the age of two years, and only 6 above that age. 

Causes. — The causes of internal convulsions are not fully ascertained. 
Most observers have remarked the relative frequency of the disease during 
the period of dentition, and it is probable that dental evolution does operate 
as a cause by rendering the nervous system more impressible. 

Spasm of the glottis has been attributed to enlargement of the thymus 
gland, and also to enlargement of the cervical and bronchial glands. It is 
presumed that this effect is due to the pressure of these glands on the par 
vagum or the recurrent laryngeal nerve. It is certain, however, that there 
is no such enlargement of the thymus gland which could possibly produce 
glottic spasm or any other form of internal convulsion at the age at which 
these convulsions commonly occur. This gland is largest in the new-born, 
and, having no function after birth, it gradually becomes atrophied. If an 
enlarged thymus could produce glottic spasm, it would certainly occur most 
frequently in the new-born. Abnormal development of the thymus gland 
seemed to be the cause of atelectasis in two infants who died soon after birth 
in my practice, but I have not seen a case in which a convulsive attack was 
referable to this cause. M. Herard examined the thymus gland in 6 children 
who died of internal convulsions and in 60 who died of other affections, and 
was not able to discover in its condition any causal relation to this disease. 
Indeed, cases have been reported in which the thymus had undergone more 
than its usual atrophy at the time when th-e convulsions occurred (Haase). 
Enlargement of the lymphatic glands in the vicinity of the pneumogastric or 
recurrent laryngeal nerve may possibly give rise to glottic spasm, but this is 
doubtless an infrequent cause, if it be a cause at all, since these glands are 
often greatly enlarged in strumous and tubercular diseases without such a 
result. According to Dr. Jacobi : ^ " In some cases described by Dr. Fried- 
leben a congenital hypertrophy of the thyroid gland has probably been the 
cause of laryngismus. The patients were new-born infants of normal devel- 
opment and born by normal labors. There were no constitutional causes of 
the disease, but a remarkable vascular swelling of the thyroid gland. When- 
ever the swelling increased the veins of the face and head increased in size 
also, the face grew livid, and the extremities and spinal column exhibited 
slight tonic convulsions. The recurrent nerves were entirely surrounded by 
the glandular tissue, their neurilemma looked unusually red, and their func- 
tions were probably injured during the occasional swelling taking place dur- 
ing lifetime" (Jacabi). 

The cause is occasionally located in the cerebro-spinal axis. Thus, Dr. 
Coley relates a case in which an exostosis arising from the internal surface 
of the occipital bone pressed upon the cerebellum, while nothing abnormal 
was discovered in other organs. Examples are also related in which the 
cause was located in the spinal cord. Thus, Marshall Hall relates the case 
of a child with spina bifida who was attacked with croup-like convulsions 
whenever it lay so as to press on the tumor. 

Internal convulsions are also frequent in rachitic softening and absorp- 
tion of the calvarium, since, when this is present, undue pressure occurs 
upon the brain by the weight of the head of the child upon the pillow. 
1 :N. Y. Jour, of Med., Jan., 1860. 



592 ' INTERNAL CONVULSIONS. 

In some patients there is evidently an hereditary predisposition to this 
disease, those affected belonging to families in which a tendency to convul- 
sive maladies is manifested. Thus, Toogood states that five infants of the 
same family were affected with spasm of the glottis ; and Reid relates, on 
the authority of Powel, that of thirteen infants of the same parents only 
one escaped internal convulsions. 

The common predisposing cause is an excitable state of the nervous sys- 
tem, often associated with impaired general health. Hence the disease is 
more prevalent in cities, where antihygienic conditions abound, than in the 
country. Hence, too, the frequent improvement when the patient is removed 
to the pure and bracing air of the country. The use of insufficient food or 
food of a bad quality must for the same reason be considered a cause, since 
it leads to impoverishment of the blood and renders the nervous system more 
impressible. Facts mentioned by Reid and others show conclusively the influ- 
ence of premature weaning and the use of indigestible or otherwise improper 
aliment in the production of this disease. 

The causes enumerated above are for the most part predisposing ; occa- 
sionally they are the only apparent causes, since this disease sometimes occurs 
when the child is tranquil, even in the midst of quiet sleep or when it is at 
rest in its mother's arms. In other cases and more frequently there is an 
exciting cause, often trivial. Anything that requires exertion on the part 
of the infant or that excites strong emotions may be a direct cause, as anger 
or any of the violent passions; so may even coughing, or, in rare instances, 
attempts to swallow. One author has known it to occur from excitement 
produced by examining the throat with a spoon. In a case of my practice, 
hereafter related, it occurred whenever the infant cried violently. It appears 
from the above facts that the etiology of internal convulsions is very similar 
to that of eclampsia. The same spasmodic muscular contraction may occur 
from a variety of causes. 

Anatomical Characters. — While, therefore, structural changes in 
various parts of the system may give rise to internal convulsions, this dis- 
ease, so far as ascertained, presents no anatomical characters, and must conse- 
quently be considered one of the neuroses. The lesions of the respiratory 
apparatus which are seen at post-mortem examinations are due to the convul- 
sions or are coincidences. Emphysema has sometimes been observed as a 
result, it is believed, of the spasmodic and irregular respiration. It was pres- 
ent in all of Herard's cases, and Rilliet and Barthez consider it common in 
those who die of this affection, although they did not observe it in any of 
their cases. Slight emphysema in the upper lobes is, however, a common 
lesion in feeble infants, whatever the diseases of which they die. Therefore 
its occurrence in internal convulsions is probably due more to molecular 
change in the lungs, since these patients are cachectic, than to the irregular 
breathing, which is only momentary. 

In fatal cases of internal convulsions the blood is darker than usual, from 
an excess of carbonic acid ; and in some cases the cavities of the heart and 
large vessels are engorged with blood, but in others they contain no more 
than the normal amount. More or less passive congestion occurs in the inter- 
nal organs ; and congestion of the cerebral vessels is in some patients so great 
that transudation of serum occurs. 

Symptoms. — I have said that the symptoms vary according to the seat 
and function of the muscles which are affected. There is generally previous 
ill-health. The child is drooping, and is sometimes restless, for days before 
the disease appears. Finally, if the muscles of the glottis become affected, 
the peculiar crowing sound is heard now and then during inspiration. It 
is observed especially when the child is crying or is agitated. It may be loud 



SYMPTOMS. 59^ 

and well defined from the first, but in most patients it comes on gradually, 
so that several days elapse before its full stridulous character is developed. 
The attacks are more frequent and severe at night, in or after the first sleep, 
than in day-time. 

Under favorable hygienic conditions the malady may pass off without 
becoming more serious. In other cases the paroxysms gradually increase 
in frequency and severity. The dyspnoea in the attack is such that the fea- 
tures are livid, the head forcibly retracted, and death seems imminent from 
apnoea. In these severe paroxysms respiration often ceases entirely for a 
moment. When the spasm ends a deep stridulous inspiration occurs, after 
which the breathing is natural. I have stated also that internal convulsions 
are often associated with those — usually tonic, but sometimes clonic — of the 
external muscles. In the tonic form the thumbs are flexed across the palms 
of the hands, and sometimes are grasped by the fingers ; the great toes are 
adducted and the other toes flexed. In severe cases the hands, forearms, feet, 
and legs are also somewhat flexed and rigid. At first the contraction of the 
external muscles is temporary, either corresponding with the internal spasm, 
or it is most intense at the time of the spasm, though commencing sooner and 
subsiding later. After a while, however, if the disease continue, the spas- 
modic action of the external muscles becomes more persistent. In severe 
cases nearly every inspiration is accompanied by the whizzing sound, and the 
paroxysms of dyspnoea are excited by trifling causes. Anything that sud- 
denly disturbs the mind or body may bring on the attack, as anger, the 
impression of cold, or currents of air. Dr. West calls attention to the fact 
that an anasarcous condition is sometimes present, accompanied by albumi- 
nuria. 

If the convulsions afl"ect other muscles, as the diaphragm or the pectoral 
and abdominal muscles, which are concerned in the respiratory function, 
while those of the larynx escape, respiration is irregular, or even suspended 
for a moment, but the stridulous laryngeal sound is absent, as there is no 
obstacle in the larynx to the entrance of air. In this form of the disease 
the inframammary region may be strongly retracted during the paroxysm 
from tonic contraction of the diaphragm. In severe paroxysms, whether the 
spasm be laryngeal or diaphragmatic, consciousness is nearly or quite lost, the 
features may be pallid, or, if respiration be suspended, may be more or less 
livid. Relaxation of the sphincters of the bowels and bladder, with invol- 
untary evacuations, often occurs in this disease during the attack. 

The duration of the paroxysm may be a quarter, a half, or even a whole 
minute. Total suspension of respiration for even half a minute involves 
danger. In mild cases there may be but few paroxysms, and they slight. 
In other instances they occur in a severe form almost daily for several weeks 
or even months. In the following case the muscles of the larynx were appa- 
rently not involved. The patient was scrofulous, and has since had scrofu- 
lous periostitis, with necrosis and exfoliation of the surface of the tibia. At 
the time of the internal convulsions she had, as seen by the history, a scor- 
butic or hemorrhagic cachexia : 

Case. — On the 28th of August, 1858, a German female infant, fourteen 
months old, nursing and having eight teeth, was suddenly seized with clonic 
convulsions. Uniformly delicate and pallid, she had been in her usual health 
till the age of twelve months, when she had a single convulsive attack, and from 
that date had remained well till August 27th, when, without any premonitory 
symptom, she had a stool consisting of almost pure blood, black and offensive. 
On the morning of the 28th a similar evacuation occurred, and another in the 
afternoon immediately preceding the convulsion. Pulse 128 after the convul- 
sion ; surface cool and pallid; flesh soft, but no emaciation. Turpentine was 
38 



594 INTERNAL CONVULSIONS. 

prescribed in two-drop doses every two hours, and laudanum in one-and-a-half- 
drop doses repeated sufficiently often to ensure quietude. 

On the 29th the pulse was 152. At 1 p. m. she had a general convulsion, 
lasting about five minutes ; in the evening she had an evacuation similar to 
those passed on the preceding day. The record for August 30th states : " Pulse 
150 to 160 ; up to this time has been playful, but is now drowsy, and, when dis- 
turbed, fretful; manifests no desire for solid food, as before her sickness, but still 
nurses ; has taken up to this time thirty-two drops of turpentine. When she 
cries or frets she has a spasmodic attack." This was the commencement of inter- 
nal convulsions, with which this child was affected for several months. An oppor- 
tunity was afforded of observing their character, for her excitement when she 
was examined was usually sufficient to produce them. After a succession of 
short expirations respiration ceased ; for a moment she was apparently insensi- 
ble ; eyes closed ; face pallid ; no frothing at the mouth. The return of conscious- 
ness and respiration was without any laryngeal rale, and after the attack she 
seemed as well as before. No external convulsion and no evacuation of blood 
occurred after August 31st. 

There was gradual improvement in her health, but she continued for many 
months pallid and irritable and subject to attacks of internal convulsions. On 
the 11th of April, 1859, when twenty-two months old, she had another attack of 
general convulsions. The record made on that day is : " Has had internal con- 
vulsions (one or more paroxysms) almost every day since last August, brought 
on usually by crying when she is corrected in any way or her wishes are refused." 
Again, on December 1, 1859, it is stated: "Has grown considerably since the 
last record, and appears to have recovered, except that at long intervals the 
spasms still occur." She took a preparation of iron, but her recovery seemed to 
be due more to the growth and development of the body and to hygienic than 
therapeutic measures. 

The general health in internal convulsions is more or less impaired, except 
in mild forms of the disease, in which the convulsive attacks soon cease. 
Pallor or a sickly and cachectic aspect, irregular, usually constipated bowels, 
poor appetite, and moroseness or irritability of temper are common symp- 
toms of severe and protracted cases. 

Diagnosis. — This disease is easily diagnosticated, unless when its symp- 
toms are masked by those of external convulsions ; it may then escape notice. 
Spasm of the glottis may be mistaken for spasmodic laryngitis, and vice versa. 
In some of the published cases this mistake appears to have been made. 
Spasmodic laryngitis is, however, so different not only in its nature, but in 
its clinical history, that a differential diagnosis is not difficult. It is an inflam- 
matory disease, and is attended with feeble reaction and a sonorous cough ; 
it commences at night after the first sleep and from exposure to cold — partic- 
ulars in regard to which it contrasts with true spasm of the glottis, which 
in complicated cases is not attended by any febrile symptoms. 

Prognosis ; Modes of Death. — Statistics show great mortality in this 
disease. Dr. Reid, in a monograph on '' Infantile Laryngismus," states that of 
289 cases which he collated, 115 died. Rilliet and Barthez met with 1 favor- 
able case in 9 unfavorable, and Herard 1 in 7. If the paroxysms be mild, 
infrequent, and dependent on a cause which can be easily removed, recovery 
is probable with proper treatment. The cause may, however, be such, even' 
when the spasm is mild, that the case is necessarily unfavorable, as when it 
is due to disease of the cerebro-spinal axis. We should not, however, in any 
case consider the patient entirely safe, since grave symptoms may suddenly 
arise, so as to change entirely the prognosis. Long and severe paroxysms, 
with lividity of face and symptoms of suffocation, indicate an unfavorable 
result. The same should be predicted also if the infant gradually lose flesh 
and strength, especially if the face be pallid, the pulse feeble, and the appetite 
poor. 

There are three modes of death in internal convulsions. The first is by 



TREATMENT. 595 

apnoea. The infant dies suffocated in the attack. Respiration is first arrested, 
and then the pulse ceases, and at the autopsy the lungs and the cavities of 
the heart are found engorged with dark blood. Death may also result from 
the state of the brain. In such cases passive congestion of the brain occurs 
from obstruction to the return of blood from this organ to the heart and 
lungs ; and if this congestion be not soon relieved serous effusion also occurs. 
Death results from the congestion and consequent oedema or dropsy. 

The third mode of death is from exhaustion. Repeated and severe attacks 
undermine the constitution ; the infant gradually grows pallid and thin, and 
dies of inanition or of some disease which this state induces. 

Treatment. — The treatment of internal convulsions has varied according 
to the theories which physicians have held in reference to its cause. Gland- 
ular enlargement is no longer regarded as a common cause, and therefore 
treatment directed to its removal is less frequently prescribed than formerly. 
The causes of internal convulsions are in part very similar to those of eclamp- 
sia, and the remedies employed in the one affection are, in a measure, appro- 
priate in the other. That dentition is sometimes a cause is usually admitted, 
and two cases, one of which occurred in my practice and the other was reported 
to me, appeared to show that it may operate as a cause. The effect of 
dentition is especially observed in weakly infants when several dental fol- 
licles are undergoing active evolution. Thus, in one of the cases to which I 
refer five teeth pierced the gums in the course of two weeks ; after which no 
convulsive attack occurred. If, therefore, the gums are swollen, the propriety 
of scarification should be considered, especially if the convulsions be so severe 
as to endanger life. 

In all cases of internal convulsions a careful examination should be made 
in order to detect any aberration from the normal state which might cause 
nervous excitation. The condition of the digestive organs should be ascer- 
tained, and evacuants or other remedies prescribed if there be evidence of 
their derangement. 

Sometimes the alimentation of the infant is at fault. It is perhaps bot- 
tle-fed and the stools have an unhealthy appearance. Attention should be 
given to the preparation of its food and the times of its feeding, or if it 
nurse the mother or wet-nurse who suckles it should have plain but nutri- 
tious diet, live with regularity, and give the breast to the infant at regular 
intervals. If there be a torpid state of the intestines. Dr. Meigs recommends 
" castor oil and aromatic syrup of rhubarb rubbed up together, three parts of 
the former and five of the latter." A simple enema answers well in such 
cases, and in debilitated infants this is preferable to medicine administered 
by the mouth. If diarrhoea be present, and it persist after the requisite 
changes are made in regard to the diet, remedies calculated to relieve it, 
which are mentioned elsewhere, should be employed. Marshall Hall states 
that he has ordinaril}^ succeeded in curing the disease by attending to the 
condition of the gums and digestive organs. 

Since rachitis is a not uncommon cause, the child should be examined in 
reference to rachitic manifestations, and if they appear the treatment appro- 
priate for rachitis is required. 

In pallid and cachectic infants tonics are indicated. The elixir of cali- 
saya-bark with iron, in half-teaspoonful doses three or four times daily to an 
infant of two years, is an eligible preparation. The preparations of iron are 
frequently to be preferred to the vegetable tonics, as the citrate of iron and 
bismuth, citrate of iron and quinia, the syrup of iodide of iron, or the wine 
of iron. To an infant of one year the syrup may be given in doses of three 
drops, the citrates in one-grain doses, and the wine in doses of one teaspoonful, 
every four hours, or the liquor ferri peptonati may be employed. 



596 INTERNAL CONVULSIONS. 

Antispasmodics, as asafoetida, valerian, and oxide of zinc, are often pre- 
scribed in this malady, but they are less efficacious than the general tonic 
measures which I have mentioned. The salutary effect of bromide of potas- 
sium in eclampsia and epilepsy certainly justifies the trial of this agent in 
internal convulsions if they persist after the employment of invigorating 
remedies. 

Hygienic measures are of the utmost importance. The infant should 
reside in dry and airy apartments, and should be kept much of the time 
through the day in the open air. Remarkable success sometimes attends 
this simple expedient when medicines have entirely failed. Mr. Robertson ^ 
of Manchester relates five severe cases in which this disease was cured by 
exposure of the infants several hours daily to a cool atmosphere. These 
cases were treated in the winter months, and were kept outdoor even dur- 
ing strong winds. Mr. Robertson has records of forty cases, all occurring 
between December and April, while he has seen no case in the summer 
months. As the result of such extensive experience the writer recommends 
" the free exposure of the infant out of doors for many hours daily to a dry, 
cold atmosphere, and, if the air be dry, the colder the better." Dr. Marshall 
Hall's experience was similar. Says he : " The curative influence of the air, 
and especially of the sea-breezes, is not less marked in this affection than in 
whooping cough." Mr. Robertson recommends also, as part of the tonic 
treatment, "free sponging of the body every morning with cold water." In 
February, 1867, I attended a nursing infant five months old with internal con- 
vulsions, the paroxysms being attended with lividity of the face and at times 
tonic convulsions of the limbs. Among the remedies employed was bromide 
of potassium, but more benefit obviously accrued from keeping the infant 
much of the time in the open air than from the medicines employed. The 
disease passed off in six or eight weeks. 

Unless the cause be of such nature that it cannot be removed, the above 
hygienic and therapeutic measures will, in a large proportion of cases, be fol- 
lowed by a satisfactory result. 

The mother or nurse may abridge the paroxysm by raising the infant, 
blowing upon it, sprinkling water in the face, or gently stroking it. Dr. 
Hall recommends tickling the nostrils with a feather to produce respiration, 
or the fauces to occasion vomiting, and thereby interrupt the paroxysm. 
Anything which causes a sudden and profound effect upon the system 
may abridge the attack. This was effected in one case in the practice of 
Dr. C. C. Meigs by applying a cloth wrapped around ice over the epigas- 
trium and the lower part of the sternum. The chief danger during the 
attack is from congestion of the brain, with effusion of serum or extravasa- 
tion of blood. If the attack be severe and the features congested, so that 
there is evident danger of such a result, cold applications should be made to 
the head, derivatives applied to the extremities — as sinapisms or mustard 
foot-baths — and the bowels should be speedily opened by enemata. 

^ London Med. Gazette, Jan. 14, 1865. 



TETANY. 597 



CHAPTER XIII. 

TETANY. 

The disease known as tetany has probably always existed, for its recog- 
nized causes are of common occurrence, but the attention of the profession 
was first directed to it by a memoir bearing the title " Observations sur une 
Espece de Tetanos intermittent," published by M. Dance in the Archives 
generales de Medecine in 1831. He described it as it occurs in the adult. 
In the following year (1832) M. Tonnele published in the Gazette medicale 
an essay on tetany, which he designated a new convulsive disease of child- 
hood. In the same year Constant and Murdoch also published their obser- 
vations on this malady in French medical journals, the former designating it 
" contractures essentielles," and the latter " retractions musculaires et spas- 
modiques." In 1835 the memoir of De la Berge on tetany, bearing the 
title "retractions musculaires de courte duree," was published in the Journal 
Hehdomadaire. From this time the disease was fully recognized in France, 
and several additional monographs relating to it appeared in medical journals 
prior to 1850, among the most notable of which was the thesis of Delpech 
in 1846. The term tetany (tetanic) was first employed by Dr. Lucien Corvi- 
sart in an interesting and instructive paper published in 1851. 

The term tetany is applied to a disease which is characterized by tonic 
contraction of muscles, commonly those of the extremities, but sometimes 
also those of the face or trunk, produced by causes external to the nervous 
system, and usually of temporary duration. ^The exception to this definition 
■might be as regards such causes as are psychical or emotional, if such exist. 
Following this definition, we would exclude cases of tonic muscular contrac- 
tion, however close the resemblance, which arise from disease of the brain, 
spinal cord, or their meninges, or from disease of the nerve supplying the 
affected muscle. The contractions in these cases are not the malady itself, 
as in tetany, but are merely symptoms of some important disease located 
in the nervous system at a distance from the afi"ected muscles. 

Causes. — Tetany may occur at any age, but is most frequent in infancy, 
in early childhood, and in early adult life. Of 28 cases observed by Rilliet and 
Barthez, 1 was at the age of nine months, 13 between the ages of one and 
two years, 5 at the age of three years, and the remaining 9 between the ages 
of three and fifteen years. Eustace Smith says that the period during which 
the largest number of cases occur is between the first and third years. In 
142 cases collated by Growers the ages were as follows : Between one and 
four years, 34 ; between four and nine years, 8 ; between nine and nineteen 
years, 36 ; between nineteen and twenty-nine years, 24 ; between twenty- 
nine and thirty-nine years, 23 ; between thirty-nine and forty-nine years, 13 ; 
and between forty-nine and sixty-one years, 4. Erb remarks that a strong- 
tendency to tetany is exhibited in early childhood, and the next most common 
period of its occurrence is at the age of puberty and early youth. The 
statistics of difi"erent observers show that tetany is more common in males 
than females. Of Rilliet and Barthez's 28 cases, 20 were boys. Of the 
142 cases embraced in the statistics of Gowers, 76 were males and 66 
females. According to Gowers, in the first and second decades, in which a 
large majority of the cases occur, more males are affected than females, 
but between the ages of twenty and fifty years females proponderate, while 



598 TETANY. 

above the age of fifty years all the recorded cases have been males. It is 
seldom that the most thorough mvestigation elicits any inherited predisposi- 
tion in cases of tetany to nervous or other diseases. Most of the observed 
cases have occurred singly in families, and in families which exhibit no spe- 
cial tendency to nervous or other ailments. Rarely, however, multiple cases 
have occurred in families, from which we infer that there may be an inher- 
ited neuropathic tendency. The only instances of this sort which I have 
been able to find in the literature of tetany were 2 cases observed by Mur- 
doch in one family, and cases alluded to by Abercrombie, who states that 
at different times 4 cases occurred in each of two families, and 2 cases in 
another family. 

Although in many instances different causes appear to act simultaneously 
in causing tetany, nearly all writers who have contributed to the literature of 
this malady assign the most important place in the causation to diseases of 
the digestive apparatus. Trousseau states that in the cases which have 
fallen under his observation diarrhoea has been commonly present. He says 
that in 1854 he met many cases following cholera, but in one instance occur- 
ring in his practice the cause seemed to be obstinate constipation. The 
patient at the age of seventeen years was suddenly seized when travelling. 
His fingers were bent and he could not extend or use them. The tetany 
subsided in two or three hours, but it recurred every day for three months. 
He was treated by bleedings, but the tetany was uniformly worse after each 
loss of blood, the contractions becoming more severe and also more general. 
Not only were the muscles of the extremities in a state of tetanic contrac- 
tion, but also those of the face and trunk, so that respiration and speech were 
embarrassed. Although the contractions were aggravated by bleeding, and 
were never so bad as after the fourth venesection, they ceased entirely for a 
period of ten months after cupping along the spine. Subsequently they 
recurred every year at the close of winter and continued two months. The 
patient was habitually constipated, and the torpid state of the bowels seemed 
to be the chief factor in producing the tetany. In the following case, which 
I have recently had under observation, constipation appears also to have been 

the chief cause : Greorge C , without teeth and at the age of seven months 

when tetany commenced, was taken from the breast at the age of two months. 
He lives in a tenement-house, and from the time of weaning has been fed with 
condensed milk, one heaped teaspoonful of large size to fifty of water. Besides 
this, he has taken once daily a tablespoonful of Nestle's food in ten of water. 
With this diet his growth has been about like the average, but he has been 
habitually very constipated, so as frequently to require assistance in obtain- 
ing an evacuation. Recently, groups of muscles in all the extremities have 
undergone tonic contraction, producing deformities, as shown in the photo- 
graph (Fig. 37), and brief attacks of laryngismus stridulus. These 
attacks of spasm of the glottis occur both by day and by night, causing for 
a moment the characteristic stridulous respiration. The mother states that at 
times he is feverish, probably from the constipation, but usually he seems 
entirely well, except as regards the sluggish state of the bowels and the con- 
tractions. Attempts to straighten the fingers and toes elicit cries from the 
pain. The mother also says that at times both thighs and both legs -are 
flexed, and he resists attempts to straighten them on account of the pain. 
The treatment employed consisted in the use of bromide of potassium and 
measures designed to relieve the constipation. When these remedies were 
perseveringly employed, the contractions gradually diminished and ceased, but 
they returned when the treatment was discontinued. Four months have 
elapsed since the commencement of the disease, and it is only in the last 
week or two that the contractions have entirely ceased. The important 



CA USES. 



599 



factor in producing the tetany in this case appears to have been the 
habitual constipation. One tooth pierced the gum during the four months 
of tetany. 

Fig. 37. 




Photograph of a Child, sho-vving Tonic Contraction of Groups of Muscles of the Extremities as 

the Result of Tetany. 



Erb says that all forms of intestinal disease may cause tetany, but it 
especially occurs after " protracted and exhausting diarrhoea." Gowers also 
remarks that the most common cause of tetany is diarrhoea, " usually long- 
continued and exhausting, but sometimes acute and brief." Among the 
rarer intestinal causes of tetany may be mentioned the presence of worms. 
I have not found in the literature of tetany any instance in which lumbrici 
or ascarides caused the contractions, but Growers alludes to three cases in 
which they were produced by the tape-worm. 

From the nature of tetany, and from the important part long assigned to 
dentition in producing nervous ailments, it is perhaps remarkable that the 
teething process has so seldom been regarded as a factor in causing tetany in 
young children. But, so far as I have been able to learn from memoirs and 
recorded cases, those who have made special study of tetany agree for the 
most part with Trousseau, who says that in nearly all instances pathological 



600 TETANY. 

conditions distinct from dentition are present, " on which tetany would seem 
rather to depend." Nevertheless, in the following case which was treated by 
Professor E. Gr. Janeway and myself, after repeated and thorough examina- 
tions teething was regarded by both of us as the chief cause of the con- 
tractions : 

Case. — B , aged twenty months, well-nourished, has during the last few 

days been unable to use the left lower extremity. The thigh is flexed at an 
angle of about forty-five degrees, and the leg at about the same angle, and 
attempts to overcome the rigidity of the flexors and straighten the limb are 
resisted and are painful. The muscles in the other extremities, and those which 
move the foot and toes of the affected limb, appear to have their normal func- 
tional activity, as do those of the face, neck, and trunk. The gums were swollen 
and congested over the crowns of five advancing teeth, which appeared to be in 
nearly the same stage of development, and were evidently soon to protrude. It 
is possible that a rather sluggish state of the bowels may have been a factor in 
causing the tetany, but the chief agent was apparently "the cutting of so many 
teeth. There was not at any time any notable elevation of temperature, loss of 
appetite, or derangement of the functions of important organs, iDut the contrac- 
tions continued three weeks, when all or nearly all the imprisoned teeth escaped 
and the limb was quickly restored to its normal state. There has been after the 
lapse of two years no return of the tetany. 

Tetany is more liable to occur in those whose systems are enervated by 
pre-existing disease than in those who are robust. Rilliet and Barthez state 
that in cases which have come under their observation the patients were often 
in poor health, resulting from disease which they had had, as pneumonia, 
bronchitis, or enteritis. Bouchut also remarks that tetany occurs as a sequel 
of various enervating maladies, among which he enumerates cholera, typhus 
and typhoid fevers, and dysentery. Erb mentions the following diseases which 
sustain a causal relation to tetany or in the convalescence from which tetany 
is liable to occur : typhoid fever, measles, cholera, Bright's disease, febris 
intermittens, in addition to the diarrhoeal maladies which have been alluded 
to above. Eustace Smith goes farther, and states that tetany is rare in 
robust subjects — that it ordinarily occurs in those who have delicate consti- 
tutions by inheritance or disease or are imperfectly nourished. Gowers, 
enumerating the maladies which are followed by tetany, mentions " typhoid 
fever, cholera, smallpox, rheumatic fever, measles, febricula, catarrh, and pneu- 
monia ;" and he states also that in young children the indications of rachitis are 
rarely absent. 

Another recognized cause of tetany is taking cold. Exposure to wet and 
cold has in numerous instances been followed by tetany. From this mode of 
origin the opinion arose that tetany is a rheumatic affection. Hence, Eisen- 
mann applied to it the term brachiotonus rheumaticus, and Benedict desig- 
nated it rheumatische contractur. Erb says : " Amongst the exciting causes, 
catching cold is both the most important and the most common ; and this 
statement," he adds, " is supported by the fact that many physicians have 
regarded it as an exquisite example of rheumatic disease. Working in the 
wet or cold or in water, sleeping on the damp ground, have very often been 
regarded as causes, and the swelling in the joints which occurs in miany 
instances indicates that this disease has a somewhat close relation to true 
rheumatism." It must be recollected that Erb's observations have been 
chiefly with adults. As regards infancy and early childhood, other causes 
of tetany are apparently more common than taking cold. Adults with 
tetany often attribute the attack to exposure in wet and inclement weather, 
and probably correctly. At the present time, in Charity Hospital, a female 
aged thirty-nine years is under treatment for tetany. She said that her sick- 



SYMPTOMS. 601 

ness was produced b}^ exposure in wet and cold weather. She was employed 
as a seamstress, and, being insufficiently clothed, sat at her work with feet 
chilled and wet. At the same time her menstruation had been irregular, and 
she had diarrhoea, apparently produced b}' the exposure. Tonic contractions 
occurred in the muscles of the fingers and toes on both sides, accompanied 
by pain, especially in the affected muscles of the lower extremities. Several 
months have elapsed since the commencement of the disease, and the fingers 
have regained nearly or quite their normal state, but the toes are firmly 
flexed. The chief cause of the tetany in this case appeared to be taking 
cold, from which probably the diarrhoea resulted, which, as we have seen, is 
one of the most common causes of the tonic contractions. Trousseau also 
relates cases in whi<?h exposure to cold was apparently the exciting cause. 
Gowers also states that next to diarrhoea the most common causes are " expo- 
sure to cold, acute disease, and lactation." 

Among the other recognized causes of tetany we may mention suckling, 
pregnancy, and the development at the time of commencing puberty. The 
first cases seen by Trousseau in Necker Hospital occurred in women recently 
confined who were wet-nursing, so that at first he designated the disease 
rheumatic contraction occurring in nurses,. Gowers says that the frequency 
of the disease in adult women is chiefly due to maternity. The following are 
occasional causes mentioned by various writers : anaemia, prolonged muscular 
effort, alcoholism, onanism (Gowers), ergotism, violent excitement (Erb), irri- 
tation of uric-acid calculi (Eustace Smith). 

From the nature of tetany it would seem probable that it might occa- 
sionally result from preputial irritation, but I have not been able to find the 
history of any case in which this cause was assigned, either in the literature 
of tetany or in monographs relating to a narrow, irritated, or inflamed pre- 
puce. Tetany does not result, or very rarely results, from burns or ordinary 
wounds ; but Weiss in 1883 reported 13 <?ases in which it occurred from 
excision of the thyroid, and, according to AVolfler, in 70 cases of this opera- 
tion tetany resulted 7 times. 

It is remarkable that this disease appears to occur as an epidemic — a fact 
not easy of explanation, unless upon the supposition that the rheumatismal 
cause due to atmospheric conditions, or the psychical or emotional cause 
giving rise to imitation, is operative at the time. Bouchut says that tetany 
occurred as an epidemic in Germany in 1717, in Belgium in 1846, and in 
Paris in 1855. In the Par^s epidemic it occurred equally among children 
and adults, and was the occasion of interesting observations by Aran and 
Barthez. Another epidemic occurred in Paris in 1876 and in its environs, 
especially at Gentilly, where in a .school the teacher and thirty pupils were 
affected ; but some of the pupils afterward confessed that they had feigned 
the disease. In New York City, in the first quarter of 1889, I saw so many 
cases that it seemed to me that tetany might properly be regarded as an 
epidemic. 

Symptoms. — Ordinarily, tetany occurs without any marked premonitory 
symptoms, but in some instances it is preceded by pain in the head or spine, 
vomiting without any previous indigestion or gastric derangement, and a 
general feeling of indisposition. Usually, in those old enough to express 
their sensations, tetany begins with tingling, burning, or other unusual sen- 
sory manifestations in the limbs. The tonic contractions occur suddenly, 
sometimes in the upper and lower extremities simultaneously. Barely, the 
contractions occur in the upper extremities alone or in the muscles of the 
trunk. At first a feeling of stiffness is experienced, and this is followed by 
tonic contractions, with the fixing of the affected part in a state of per- 
sistent flexion or extension. Usually, as regards the upper extremities, the 



602 



TETANY. 



contraction of the thenar and hypothenar muscles causes hollowness of the 
palms of the hands ; the first phalanges of the fingers are flexed, the second 
and third phalanges extended, and the thumb adducted and flexed so as to 
press against the index finger or lie underneath it. The fingers sometimes 
incline toward the ulnar side, and sometimes are pressed against each other. 
Usually the hand is slightly flexed, as is also the forearm. The muscles 
which move the arm usually escape, but exceptionally there is adduction of 
the arm on the shoulder. The hand may be extended instead of flexed, 
and all the joints of the fingers extended, or they may all be flexed and the 
fist closed. 

The thighs may be adducted or flexed, the legs extended or flexed, the 
foot extended, forming a talipes equinus, and the toes flexed, as in the fol- 
lowing interesting case now in Charity Hospital, which has been alluded to 
above. Though the patient is an adult, her case is related here, since it aids 
in throwing light on the nature of the disease : 

Case. — Mary F. O , native of the United States, seamstress, married, and 

of apparently healthy parentage, states that her health was good previously to the 
present sickness. She says that she has never had venereal disease and never 
taken stimulants in excess, though in the habit of using whiskey at breakfast. 
She had been married four years, and three years ago had a stillborn child at the 
seventh month, but has had no other miscarriage and has had no confinement at 
terra. Her catamenia, which formerly were scanty and at unusually long inter- 
vals, have during the last four months been normal in regard to time and quan- 
tity. She has been subject to afternoon headaches for years. She has had the 
average appetite, has partaken largely of rye bread at her meals, and her stools 
have been normal. 

In January, 1 888, the patient, being employed as a seamstress in a shop at a 
distance from her residence, began to experience unusual fatigue, and on return- 

FiG. 38. 




ing from her day's work she frequently noticed a painful burning sensation in 
her feet, the pain extending upward along the calves of her legs. This pain in 
the feet and legs gradually increased until March 12, 1888, at the time of the 
deep snow accompanying the " blizzard." After walking through the snow she 
sat all day at her work with wet feet, and at this time she began to experience a 
dull intermittent pain extending from both ankles to the knees, and accorapanied 
by great lassitude, so that walking required an effort. In July the pain became 
more constant, but at the time of her admission into Charity Hospital (August 



SYMPTOMS. 603 

17tli) it was not so constant or severe. Soon after her admission the feet became 
strongly extended, forming a talipes equinus, and the toes of both feet were also 
strongly flexed. Sensation in the toes, but not in the feet, was almost completely 
lost. A few days subsequently the fingers on both sides were similarly flexed, 
but without pain or loss of sensation. In about six months the flexion of the 
fingers ceased, and she can now use them nearly as well as before the attack. 
The toes also are not so strongly flexed as at first, and they have regained sensa- 
tion. The bladder has never been affected, but the sphincter ani was paralyzed 
for a time in August, so that the feces escaped involuntarily in bed. The patient's 
memory was considerably impaired after the exposure at the time of the " bliz- 
zard," but is now (June, 1889) apparently nearly or quite normal. Otherwise no 
impairment of the mental faculties has been observed. 

The tetany in this case has been, as usual, bilateral and for the most part 
equal on the two sides, with a little more acuteness of sensation in the right than 
left limbs. The feet continue in the position of talipes equinus, with toes flexed, 
and the contracted muscles hard to the feel, almost like cartilage. No oedema 
has been observed, but perspiration occurs from the extremities during sleep. 

In mild cases or those of ordinary severity the contractions are limited to 
the muscles of the extremities, and are more marked and persistent in those 
that move the hands, feet, fingers, and toes than in other muscles ; but in 
severe cases the muscles of the trunk and head participate. Contraction of 
the abdominal muscles produces rigidity of the abdominal walls. Spasm of 
certain of the thoracic muscles occasionally occurs, causing dyspnoea and 
even lividity. In some of these cases of embarrassed respiration the dia- 
phragm is probably involved. Opisthotonos, retention of urine, anteflexion 
of the neck from contraction of the sterno-mastoids, fixation of the jaws from 
spasm of the masseters, retraction of the angles of the mouth, stiff"ness of 
the tongue, and indistinct articulation are occasional symptoms in severe 
cases of tetany. 

The contractions render the aff"ected muscles hard and unyielding, and the 
child cries from pain when attempts are made to straighten the limb. If the 
spasm be slight some voluntary movement of the aff"ected muscles is possi- 
ble, but it is restrained and difficult. In severe cases, with the muscles tense 
and unyielding, voluntary motion is impossible. Except in the mildest forms 
of the disease pain is felt in the contracted muscles, such as all people expe- 
rience when a spasm occurs in the calf of the leg, and the pain may pass 
upward along the limb. The pain may occur in paroxysms with distinct 
intermissions, or, without ceasing, it may vary in severity at diff"erent times, 
probably from some variation in the degree of spasm. Certain subjective 
symptoms, such as numbness and tingling, which sometimes occur in tetany, 
may continue during the intermissions or remissions. After some hours or 
days the rigidly-contracted muscles relax and the disease disappears, except 
perhaps that a degree of stiff'ness remains. But the respite is usually not 
long. The spasms recur, and several successive recurrences and intermissions 
take place, running over months, before the disease is permanently cured. 
During the intervals in the contractions the aff"ected nerves and muscles are 
in ordinary cases unduly excitable, so that sudden pressure or percussion 
causes some contraction. Trousseau was perhaps* the first who noticed and 
called attention to the fact that compression of the artery and nerve sup- 
plying the contracted muscles in tetany causes or increases the contraction. 
Occasionally this result cannot be obtained. 

It is an interesting fact that in cases which I have observed the spasms 
do not cease in sleep, though the contraction of the muscles may not be as 
great as when the patient is awake. 

The electrical excitability of the nerve which supplies the contracted 
muscles is increased. Gowers states that he has obtained contractions in the 



604 TETANY. 

muscles of the face by the voltaic current from a single cell. The increased 
excitability of the nerves is apparent if either the direct or induced current 
be used. According to Erb, when the circuit is closed the earliest contrac- 
tions occur at the point of application of the positive pole. Both opening 
and closing the circuit cause a more prolonged contraction of the muscles in 
tetany than in health. When the contractions are strong, oedema sometimes 
occurs, especially upon the dorsal surfaces of the hands. It was present in 
cases treated by Henoch, who attributes it to compression and consequent pas- 
sive congestion of the veins, produced by contraction of the interossei muscles, 
the congestion giving rise to serous transudation. When the paroxysms are 
severe, perspiration sometimes occurs, and an erythematous redness may 
appear over the affected muscles. Occasionally in acute attacks the temper- 
ature is moderately increased, but ordinarily it is normal. Tetany does not 
usually affect the functions of the internal organs, but in a case related by 
Kussmaul and another by Nonchen albuminuria was for a brief period pres- 
ent, and in one recorded instance the urine exhibited traces of sugar during 
the paroxysms. Occasionally in long-continued tetany the contracted mus- 
cles undergo a degree of atrophy which is attended by diminished electrical 
irritability. Gowers states that " general muscular atrophy " has also been 
observed following tetany. 

The following may be regarded as typical cases of tetany in infancy as 
I have observed it in New York. The following case occurred in the New 
York Infant Asylum during my term of service, and the resident physician, 
Dr. Virginia M. Davis, has kindly furnished me the history from her note- 
book : 

Case I. — Gertrude A , born in the New York Infant Asylum, April 30, 

1888, was well except a mild attack of pertussis until March 9, 1889, when she 
had a prostrated appearance, and the thermometer indicated a temperature of 
105°, and a little later 105.5°. During the following six hours she had five large, 
watery, but yellow stools. She was restless, her features sunken, extremities cool, 
her surface covered with a clammy perspiration, and her pulse feeble. Her diar- 
rhoea was checked, and she slept during the following night. From March 9th 
to 14th she had slight fever (100.4°-100.6°) and her stools were normal, but dur- 
ing the week ending with the 14th she lost one pound in weight. The following 
are the subsequent notes of the case : 

March 14th. — Is restless ; temperature in the morning 100.4°, in the even- 
ing 103°; has had no stool in the last twenty-four hours. To-day has had for 
the first time contraction of the flexor muscles of the hands, feet, fingers, and 
toes, so that in the evening all the fingers and toes are firmly flexed. The dorsal 
surfaces of the hands and feet, and the fingers and toes as far as the articulations 
of the first and second phalanges, are oedematous. The flexions can be overcome 
by the employment of considerable force, but the attempt is painful. An ery- 
thematous eruption has appeared over the upper part of the chest and upon the 
back. 

March 15th. — Temperature 100.6°; thumbs extended, voluntary movement 
of fingers returning; toes still flexed; oedema as before; rash fading; stools nor- 
mal. March 16th. Temperature 99°-99.8°. The contractures have entirely dis- 
appeared during the day. Had four stools. 17th. BoAvels constipated; slight 
contractures of the fingers. 18th. Morning temperature 103°; evening, 101°. 
In the evening contractures of both extremities disappearing; stools normal; 
gums swollen. From this time the constipation was relieved by small doses of 
calomel, and the tetany ceased. Some elevation of temperature was a prominent 
symptom previous to and during the tetany, and on one day (May 17th) an attack 
of general clonic convulsions or eclampsia occurred. The tetany ceased on the 
18th or 19th, but between the 20th and 30th maculse and papules appeared on the 
surface, due perhaps partly to the medicines employed, which were chiefly the 
bromides and chloral. 

Case II. — Edward McI , aged fifteen months (practice of Dr. Vineberg, 



SYMPTOMS. 605 

but examined by myself), lias healthy parentage, and no other child in family has 
had any nervous ailment, except a single attack of eclampsia during measles in 
one of the children. Edward is nourished in part at the breast and in part from 
the table. He has four teeth, all having cut the gum since the age of twelve 
months. He has had diarrhoea much of the time since birth, and during the last 
two months has had free perspiration from the head. The mother states that 
during the first months of his life he occasionally held his breath, especially at 
night, but with this exception no symptoms resembling a convulsive attack were 
observed until recently, when, during an attack of coughing, his face grew red, 
his eyes turned upward, and his respiration ceased for a moment. When he was 
at the age of twelve months the mother first noticed that the toes were flexed and 
the feet extended as in talipes equinus. Considerable force was required to over- 
come the tonic contraction of the aff'ected muscles, and when the pressure was 
relaxed the feet immediately assumed the former position of talipes. The thumbs 
were strongly flexed across the palms of the hands, the index and middle fingers 
forcibly extended and separated from each other, and the ring and little fingers 
were flexed against the palm. These abnormal flexions and extensions continued 
more than three months, with occasional intervals of two or three days, during 
which the action of the afiected muscles was nearly normal. The child presents 
evidences of rachitis in the shape of its head and enlargement of the epiphyses 
of the extremities. 

The treatment employed by Dr. Vineberg consisted in change of diet and in 
the use of the following prescription : 

R. Zinci sulphat., gr. j ; 

Atropiffi sulphat., gr. y|o. Misce, 
To be taken three times daily. 

With this treatment the spasms of the muscles entirely disappeared within a 
week, and two weeks later had not returned. 

It is our purpose to treat mainly of tetany as it occurs in children, but in 
order to give completeness to our remarks on this disease it is necessary also 
to describe it as it occurs in the adult. The following case, related by Trous- 
seau, gives a clear and vivid idea of the symptoms of severe tetany as it 
occurs in the adult. A dissipated young man was found one morning lying- 
in the street, •' stiiF as a poker" from the occurrence of tetany during the 
night. He was conscious and complained of great pain, but spoke indis- 
tinctly from the clenched state of his jaws. Muscles in his extremities were 
rigidly contracted, and, being unable to walk, he had fallen down and could 
not rise. The rigidity of the muscles of the chest and abdomen, and prob- 
ably of the diaphragm, rendered respiration difficult. His face was livid, and 
he had paroxysms of dyspnoea that threatened suffocation. The tetany finally 
abated, and he was able to walk and attend to slight duties, but at intervals 
he had recurrence of the spasms, and finally died of phthisis. 

Adults, unlike young children, give a clear description of their subjective 
symptoms. Frequently — probably in a majority of instances in the adult, 
as in the child — tetany is preceded by certain sensory symptoms, as formi- 
cation, a sensation of weight or dragging, of heat or cold, or even of pain. 
Soon afterward in using the limbs the patient observes some stifi"ness or that 
the movements are not so free and easy as previously. The spasms succeed, 
and, as in children, their duration and severity vary greatly in different 
patients. In the adult, as in the child, in mild tetany the contractions are 
limited to the muscles of the hands, feet, fingers, and toes, and the severe 
disease usually attacks first these muscles, and afterward extends to the 
muscles of the head, face, neck, and trunk. Cases might be cited from the 
literature of tetany in which the contractions occurred in the muscles of the 
face, causing unsightly visage, the motor muscles of the eye, causing strabis- 



606 TETANY. 

mus, the pharyngeal and laryngeal muscles, the muscles of the tongue and 
diaphragm, causing embarrassment of speech, respiration, and deglutition, 
sterno-cleido and other muscles of the neck, changing the position of the 
head, and in the various muscles of the trunk. In a case observed by 
Dr. Herard the recti muscles in the abdominal walls stood out like two tense 
cords. However severe the disease may be, a marked remission or distinct 
intermission soon occurs, the progress of tetany being characterized by 
intervals of complete relief. In not a few of the reported adult cases tetany 
has reappeared at varying intervals during a series of years, being due to the 
recurrence of the causes which first produced it. 

Pathology. — Since tetany in itself is rarely fatal, only a few post-mortem 
examinations have been made, and in these no lesions have been discovered 
which appeared to sustain a causal relation to the disease. In the spinal cord 
minute hemorrhages, points of apparent myelitis, lymphoid cells, hyperaemia 
of the spinal meninges and of the cord in their upper portions (Bouchut), 
and softening of the cord in the cervical region, have been observed in certain 
cases, but these lesions are believed to result from the excessive functional 
activity of the cord. The exaggerated excitation of the motor nerves is 
probably also attended by some change in their nutrition. Gowers says that 
change in their nutrition consequent on their excited action is undoubtedly 
present. He states that a nutritive change in the motor nerve-fibres is 
usually consequent on, and secondary to, a similar change in the motor cells 
of the spinal cord, the axis-cylinders of the nerves being prolonged processes 
of these cells. Slight changes have been observed in these cells in those 
who have had tetany severely, and the fact that this disease is bilateral 
indicates that it has a central origin. Gowers adds that the sensory nerves 
are also probably implicated, from the fact that sensory symptoms often 
precede the spasms of tetany. As to the seat of the disease, nothing fur- 
ther is at present known ; but Gowers, after a careful survey of the facts 
relating to the pathology of tetany, remarks : " On the whole, our present 
knowledge of the pathology of the disease points to the nerve-cells of the 
spinal cord and medulla as the parts chiefly deranged, and the way in which 
the cells in rare cases seem to undergo subsequent atrophy suggests that the 
disturbance is a primary one of the cells themselves, and is not produced by 
the agency of any vaso-motor mechanism. It is difiicult to conceive that 
symptoms of such definite and uniform character can be the result of any 
vascular spasm. The occasional wasting, with diminished irritability, is 
especially important as suggesting that the nutritional changes in the motor- 
cells and fibres, causing the increased excitability, may sometimes go on to 
structural degeneration." 

Diagnosis. — It may assist in the diagnosis to ascertain that the attack 
has immediately followed the occurrence of one of the recognized causes of 
tetany, as diarrhoea or other intestinal ailment or exposure to cold. We may 
diagnosticate tetany from tetanus from the fact that it is very rare under the 
age of one month, if indeed it ever occur in the newly-born, whereas tetanus 
almost never occurs in infancy after the first month or in childhood, nearly 
all cases occurring during the first three weeks after birth. It is also dis- 
tinguished from tetanus by the fact that it begins in the extremities, has 
periods of cessation or intermittence, and the masseters, which in tetanus 
early undergo the peculiar tonic contraction, are not affected or are aff'ected 
only at a late stage and in the most severe cases. 

In organic disease of the brain the contractions do not, as a rule, intermit, 
and they are frequently limited to one side ; besides, other symptoms clearly 
referable to the brain are usually present. The bilateral and symmetrical 
nature of tetany, the occurrence of the contractions in corresponding groups 



PROGNOSIS— TREATMENT. 607 

of muscles on the two sides, distinguish the disease from those contractions 
which occur from lesions in the course of the nerves. 

Prognosis. — Tetany, whether intermittent, remittent, or occurring with 
little variation in the spasms, soon ceases in some cases and never returns. 
In other instances it does not cease entirely for months, though varying in 
severity at different times. Certain patients have attacks of it at intervals 
during a series of years, their health being good when not affected by it. 
Thus the case of a woman is related whose first attack was at the age of 
twenty-two years, and who had a recurrence of the disease every winter, and 
was still having it at the age of thirty-four years. This appears to have been 
one of those cases which have been attributed to a rheumatismal cause inci- 
dent to cold weather! Lussana relates a similar case in which tetany occurred 
each winter during ten successive years. In some instances years elapse 
between the attacks, as in a case related by Choostek. Maccall states that 
a woman had tetany five times when wet-nursing five successive children, and 
was well in the intervals. 

During infancy and childhood tetany, when uncomplicated, ends favor- 
ably, with possibly now and then a rare exception. In this respect it con- 
trasts with tetanus, which, whatever the age, is, with few exceptions, fatal. 
The few cases found in the literature of this disease in which death appar- 
ently resulted directly from tetany have been, so far as I have been able to 
ascertain, adults. Dr. Blondean states that in Lourcine Hospital, Paris, a 
young woman whose health had been greatly impaired by syphilis and a mis- 
carriage had an obstinate diarrhoea. Tetany set in with great violence. The 
muscles of the face, neck, and chest were rigidly contracted. The face was 
livid, the eyes fixed, the pulse could not be counted, and the breathing was 
labored and stertorous. She was bled from the arm, and subsequently twelve 
leeches wefe ordered to be applied behind the ears, but during their appli- 
cation she died. The post-mortem examination, conducted with great care, 
revealed an apparently healthy state of all the organs except " traces of con- 
gestion in the meninges, the veins of which contained a little more dark 
blood than usual." Gowers states that death may occur in consequence of 
pulmonary congestions and a low form of pneumonia which result from 
repeated attacks of tetany. Tetany following excision of the thyroid is more 
likely to be fatal than when it occurs from other causes. But, we repeat, so 
rarely is tetany fatal that most of those who have contributed to the litera- 
ture of this disease have never observed a fatal case. Muscular weakness 
for a time, and even more or less muscular atrophy, occasionally follow an 
attack of tetany. 

Treatment. — The cause or causes of the attack, so far as they can be 
ascertained, should obviously be promptly treated, and if possible removed. 
Especially should diarrhoea or any other abnormal state of the digestive sys- 
tem receive appropriate treatment. If the patient have been exposed to cold, 
and the cause be apparently of a rheumatismal nature, warm baths and 
diaphoretics, such as are employed in breaking up a cold, may be advantage- 
ously employed. 

In the treatment of the tetany of children the bromide of potassium is a 
most useful remedy. Four grains dissolved in cold water or any convenient 
vehicle may be given every third or fourth hour to a child of from one and 
a half to two years. It is a safe remedy, and it usually causes a diminution 
or cessation of the spasms. Cannabis Indica, chloral, and hypodermic 
injections of morphia which have been employed in adult cases with apparent 
benefit should not be recommended for young children. It will be recollected 
that in the case treated by Dr. Vineberg, related in a preceding page, the 
infant at the age of fifteen months took one-quarter of a grain of sulphate 



608 CHOREA. 

of zinc and j^-^ of a grain of sulphate of atropia three times daily, and with 
this treatment and a change of diet recovered within a week. Chloroform 
inhalation has been used, and during the narcosis produced by it active 
massage treatment of the aifected limbs has been employed with apparent 
benefit. Gowers states that faradism is contraindicated, and that the best 
results have been obtained from the voltaic current, either with both poles 
applied to the spine or with the negative pole to the spine and the positive 
over the affected muscles. But the treatment by electricity, by chloroform, 
and, we may add, by ice over the spine, as practised by Trousseau, is more 
applicable to adult cases than to children. 

A large proportion of children having tetany exhibit rachitic symptoms, 
and when such symptoms are present cod-liver oil and iron should be pre- 
scribed, and at the same time that the bromide of potassium and other reme- 
dies designed to relieve the tetany are employed. 



CHAPTEK Xiy. 
CHOREA. 

Chorea, or St. Vitus's or St. Guy's dance, is a neurosis which is charac- 
terized by irregular and involuntary muscular movements, without loss of 
consciousness. The movements occur in the muscles of volition, and there 
is probably no one of them that may not be engaged, though some are more 
frequently affected than others. It is not known that any involuntary mus- 
cle is ever involved, though Sir William Jenner has expressed the opinion 
that occasionally the papillary muscles of the heart are, so that by their 
spasmodic contractions they produce insufficiency of the mitral valve. This, 
according to him, affords explanation of the fact that in certain instances a 
mitral regurgitant murmur is heard, which disappears about the time that 
the external movements cease. It is rare, however, that a mitral regurgitant 
murmur, heard during chorea, ceases when the latter terminates, and it is 
not improbable that in such cases there is, after all, a lesion of the valve, 
due to recent endocarditis, whether of a rheumatic or other origin ; for a 
valve may be so thickened by recent inflammation as to cause a murmur, and 
after a few weeks or months the infiltrating substance be so absorbed that 
the murmur is no longer audible. If we admit the fact that cardiac bruits 
occasionally appear and disappear with chorea, this explanation seems to me 
more plausible than that of Jenner. Hillier says in reference to this sub- 
ject : " My own experience leads me to doubt the existence of dynamic apex 
murmurs in chorea ; that is to say, murmurs produced in hearts entirely free 
from organic change. If such murmurs ever occur, they are certainly rare. , 
Organic murmurs of the heart, on the other hand, are common in chorea, 
and I am inclined to believe that organic disease of the heart often exists in 
chorea when there is no murmur." We shall see, by a case presently to be 
related, that this opinion is correct. Hillier also calls attention to the fact 
that choreic movements are irregular ; but a cardiac bruit occurring regu- 
larly and uniformly, if not due to organic disease, would require rhythmical 
contractions of the papillary muscles to produce it. We infer from this that 
the bruit does not have a choreic origin. 

In the class of children's diseases in the Bureau for the Relief the Out- 
door Poor in New York City, 16,986 children were treated in the two years 



AGE— CAUSES. 6^09 

and three months ending with March 31, 1877. Of these cases 82, or 1 in 
every 207, had chorea. The patients were all under the age of fifteen years. 
Statistics published by observers in Europe show that the relative frequency 
of this disease is probably about the same in the large European cities as in 
New York. Thus, according to Hillier, amongst 122,621 out-patients treated 
at the Hospital for Sick Children in London, 406, or 1 in 322, had chorea, 
while of the in-patients. 174 in 5585, or 1 in every 32, were choreic. In the 
Parisian Hospital for Sick Children, of 84,968 admitted in twenty-one years, 
531 had chorea, or 1 in every 161. 

Age. — Chorea may occur at any period of life, but a large majority of the 
cases are in childhood. It is rare in infancy and it rarely begins after puber- 
t}'. Under the age of five years the proportionate number diminishes as we 
approach the time of birth. The youngest in the statistics of Hillier was 
three months. In 1870, in the Bureau for the Out-door Poor a child was 
presented for treatment who, the mother said, had had chorea from birth, 
and in 1877, I treated a young woman with severe general chorea who, 
repeatedly questioned, uniformly said that she had had the disease, without 
any assignable cause, from the first week of her life, and her friends corrobo- 
rated the statement. The following table exhibits the relative frequency of 
chorea at difi"erent ages : 

6 years 6 to 10 10 to 15 
andunder. years. years. 

Children's Hospital, London, Hillier, none over 12 vears 

admitted ." . . 81 237 104 

M. Rnfz 10 61 118 

Bureau for Out-door Poor (prior to 1875) 2 26 16 

At and under 3 to 5 5 to 10 10 to 15 
3 years. j-ears. years. years. 

Bureau for Out-door Poor (since .January 1, 1875)~ 5 30 337 130 

M. See collected the statistics of 531 cases occurring in the Children's 
Hospital, Paris, and from them concludes that the maximum frequency of 
chorea is between the sixth and tenth years. Only 28 of his cases were 
under six years, the remainder. 503. occurring between the sixth year and 
puberty. 

Causes. — The profession are nearly agreed in regard to certain causes of 
chorea, while there is a diversity of opinion in reference to others. It is 
admitted that in a large proportion of cases there is a neuropathic state 
which antedates and predisposes to chorea. This state is often manifested 
in the family history by a proneness to affections of the nervous system, and 
in the individual by a highly excitable state of the emotions, so that he 
evinces joy. grief, or anger from slight causes. 

All writers admit that there is often an inherited predisposition to chorea. 
In 27 of 48 cases, BadclifFe found that father, mother, brother, or sister had 
been or was the subject of one or other of the following disorders : paralysis, 
epilepsy, apoplexy, hysteria, or insanity. The children of parents who when 
young had chorea or who exhibit proneness to ailments of the nervous sys- 
tem are more liable to chorea than other children. Hence the fact, some- 
times observed, of diiferent children in the same family becoming affected 
with chorea when they attain the age at which this disease ordinarily 
occurs. In one family in my practice three girls at different times were 
affected. 

Sex. — The emotions are strong in girls, since in them the nervous system 
predominates, while the muscular power is weaker than in boys. Hence a 
partial explanation of the fact which statistics fully establish, that the pro- 

39 



610 CHOREA. 

portion of choreic boys to girls is about in the ratio of one to two and a frac- 
tion. I have remarked, in this city, the large proportion of cases in school- 
girls between the ages of six and twelve years, the severe discipline and 
confinement of the public schools no doubt increasing the strength of the 
emotions, and weakening the control of the will over the muscles. 

Proportion of Males to Females. 

27 to 73. Hughes's Digest of Cases in Guy's Hospital, 1846. 

138 to 393. M. See. 

50 to 94. Out-door department, Bellevue. 

276 to 499. Children's Hospital, London West (Lumleian Lectures). 

491 to 1059 = 1 to 2.15. 

The cases treated in the Out-door Department, Bellevue, since those 
contained in the above table occurred give a larger percentage of females. 
Between April, 1878, and December, 1883, 288 choreic cases were treated 
in this department, and of these the proportion of boys to girls was 1 to 2.4 
(Chapin). 

Uterine Irritation. — The peculiar changes occurring in the female at 
puberty constitute an important cause. Hence another reason of the excess 
of female cases. Dysmenorrhoea and pregnancy are causes of a large pro- 
portion of cases in the first years of puberty. In the male, on the other 
hand, the changes of puberty do not appear to increase the liability to the 
disease, directly or indirectly, and male cases after the age of twelve years 
are comparatively rare. Radclifi'e^ states that after the ninth year females 
are more liable to chorea than males, in the proportion of 5 to 2, while before 
the ninth year the two sexes are equally liable to it. Carefully prepared 
statistics, however, notwithstanding the high authority of Radcliffe, show a 
preponderance of girls under the age of nine years, though not so great as 
over that age. In the Out-door Department at Bellevue, of 35 patients under 
the age of ten years, 22 were girls, while of 20 from the age of ten years to 
sixteen, 15 were girls. 

According to West,^ in 775 children with chorea under the age of ten 
years treated in the London Children's Hospital, 64 per cent, were girls. 

Ansemia. — Among the most common predisposing causes of chorea is 
anaemia. It is present in so large a proportion of cases, exhibiting itself by 
pallor of the countenance and other characteristic signs, that medicines 
designed to improve the C{uality of the blood are among the most efficient 
remedies. The peculiar neuropathic state already alluded to, which needs 
only a slight additional cause for the development of chorea, is no doubt 
largely dependent on impoverishment of the blood, if it be not sometimes due 
entirely to it. Among the poor of a large city like New York or in hospital 
practice the proportion of anaemic cases of chorea is, for obvious reasons, 
much larger than would appear from the general statistics. 

Rheumatisni. — Dr. Copeland, M. Bouteille, and afterward M. G-ermain 
See in a more extended monograph, directed the attention of the profession 
to rheumatism as a cause of chorea. Subsequent observations have estab- 
lished the fact that rheumatism or the rheumatic diathesis is so frequently 
present that it obviously sustains an important relation to chorea, though in 
what manner is not fully ascertained. This relation between the two is more 
frequently observed in some countries than in others. In England and 
France so large a proportion of choreic patients present a history of rheu- 
matism, either in themselves or family, that certain physicians of these coun- 
tries believe that rheumatism is the most common cause of the disease. In 

^ Reynolds's System of Medicine. ^ Lumleian Lectures. 



CAUSES. 611 

Germany, on the other hand, according to Romberg, in the majority of cases 
no relation can be traced between chorea and rheumatism. Probably the 
largest number of choreic cases treated in one institution in this country is in 
the Bureau for the "Relief of the Out-door Poor in this city ; and it has been 
our practice during the last few years to examine each patient for heart dis- 
ease and question the parents as regards rheumatism. Without referring to 
the exact statistics, I should say that more than half give the history of 
rheumatism in themselves or parents or had unequivocal signs of heart dis- 
ease. One of the physicians of the class found that 22 in 38 consecutive 
cases of chorea gave the history of rheumatism or of heart disease in them- 
selves or parents. 

Various theories have been promulgated in explanation of the relation- 
ship of the rheumatic and choreic diseases. It has been suggested that 
chorea is due to rheumatism of the brain or spinal cord. This is simply an 
hypothesis, the truth or falsity of which can only be ascertained by carefully 
conducted necropsies ; but the theory appears improbable in view of all the 
facts. Another theory attributes chorea to the state of the blood which is 
present in those having rheumatism or the rheumatic diathesis, as well as in 
certain other conditions. This theory is enunciated by Dr. Ogle, as follows : 
" Recognizing the frequent existence of these fibrinous deposits or granula- 
tions on the heart's valves in chorea, I should be much inclined to look upon 
these post-mortem appearances rather as results of some antecedent general 
condition of the blood common also to the choreic condition. It is very freely 
recognized that this aiFection is frequently, in some way or other, connected 
with that condition of blood which obtains in what we call anaemia or that 
existing in rheumatic constitutions. In both of these states we know that 
the fibrin of the blood is much in excess (as also it is in pregnancy, another 
condition looked upon as obnoxious to chorea) ; and in these states we know 
that the fibrin with which the blood is surcharged is very prone to be readily 
precipitated, either owing to its superabundance or from other obscure and 
acquired properties, .... upon the heart's walls or valves. 3Iay not this 
hyperinosis be the explanation of the coincidence alluded to?"' — namely, the 
occurrence of chorea in those afi'ected with rheumatism. Others still hold 
that chorea is the result of the heart disease, and not directly of rheumatism, 
occurring when the heart is afi'ected from other causes as well as when the 
lesion has a rheumatic origin. This theory is plausible, and probably to a 
certain extent correct. Heart lesions observed in children result from scarlet 
fever in a considerable proportion of ca^es, though it is true that the endo- 
carditis and pericarditis of scarlet fever are believed often to have a rheu- 
matic origin, occurring in some instances from scarlatinous rheumatism, but 
in other cases from scarlatinous uraemia. Occasionally also the heart disease 
appears to have occurred independently of both rheumatism and scarlet fever. 
Thus in a fatal case of chorea with valvular disease related to the London 
Pathological Society, April 6, 1869, the child was always healthy up to the 
present illness (chorea), and there was no history of rheumatism in the fam- 
ily. The more observations accumulate the more important does heart dis- 
ease in itself appear as a cause of chorea. In nearly all recorded cases of 
fatal chorea which were supposed to be due to rheumatism, and in which post- 
mortem examinations were made, endocardial and usually valvular disease has 
been found. We shall see that certain eccentric causes of irritation aid in 
producing chorea, and may not the valvular disease or the endocarditis which 
causes the valvular lesion operate in a similar manner as a cause? AVe know 
that in the adult severe cardiac disease often profoundly aff"ects the nervous 
system, perhaps in consequence of the irregular and embarrassed circulation, 
^ British and Foreign Med.-Chir. Rev., January, 1868. 



612 CHOREA. 

and certainly in the child a similar cause would be likely to produce a more 
decided effect. 

But there is an ingenious theory which attributes chorea to minute 
emboli detached from vegetations on the valves, and arrested by capillaries 
in the corpora striata or other portion of the cerebro-spinal axis. Since atten- 
tion was directed to this matter, emboli have been found in one case in the 
medulla oblongata, although this portion of the spinal axis appeared healthy 
to the naked eye. Further observations are necessary in order ro determine 
how much truth there is in this theory ; but it seems probable, for reasons to 
be stated, that if capillary embolism do cause chorea, it is only in a limited 
number of cases, and that therefore those British observers who regard it as 
the common cause have been led into error by the large proportion of choreic 
cases which in their climate are complicated by valvular lesions. 

That embolism is not a common cause, if indeed a cause at all, appears 
probable from the following facts : First. In many cases of chorea there are 
no vegetations or other appreciable lesions which could give rise to emboli. 
Secondly. Most patients recover, and some speedily, by treatment, which we 
would not expect if the cause were embolism. Thirdly. Embolism is not 
infrequent in the cerebral vessels of the adult without the occurrence of 
chorea. Indeed, the conditions which produce embolism are much more com- 
mon in adults than in children, while the reverse is true as regards the liability 
•to chorea. Fourthly. Dogs sometimes have chorea, but the injection of 
minutely divided fibrin or other substance into the veins of the dog is not 
followed by chorea as one of the phenomena. Fifthly. Were capillary emboli 
the cause, we would expect to find an occasional embolus in the larger vessels 
of the brain, so as to be appreciable to the naked eye ; but I find no examples 
of this in all the recorded autopsies which I have been able to consult. More- 
over, it seems improbable that capillary embolism, when producing no lesion 
appreciable to the naked eye, would so arrest the circulation and disturb the 
function of the brain or spinal cord as to cause chorea, for the ill-eifects 
of such an obstruction would be likely to be obviated by the numerous 
anastomoses. 

In 1877 the unusual opportunity occurred in my asylum practice of 
determining whether there are any fixed anatomical characters in the 
cerebro-spinal axis in chorea ; in other words, whether chorea is a neurosis, 
as we have designated it in our definition, and the case is so interesting in 
other respects that I shall relate it entire : 

Case. — Charles , a foundling, born October 15, 1874, was received in the 

New York Foundling Asylum soon after his birth. When two weeks old he was 
removed to a family in the city to be wet-nursed. His health continued good till 
the age of three months, when he had bronchitis and keratitis, the former mild 
and lasting only a few days, but the latter continuing nearly two months, being 
attended by moderate injection of the conjunctiva, with some purulent discharge, 
which caused adhesion of the eyelids during sleep. From this time he remained 
well, with the exception of a slight attack of dysentery, till the age of about nine 
and a half months, when he began to have febrile symptoms. In the morning 
hours he seemed in tolerable health, but at mid-day or a little later than mid-day 
of each day he was observed to have slight irregularity or embarrassment of 
respiration, and lividity, with coolness of the extremities ; which state, supposed 
at the time to be the algid stage of a somewhat irregular intermittent fever, lasted 
from one to two or three hours, and was succeeded by fever, which continued 
during the remainder of the day ; sometimes the fever abated in perspiration. 

On August 4, 1875, a few days after the commencement of these irregular 
febrile symptoms, Charles was brought to the dispensary of the institution for 
treatment, and Dr. Reid, who was on duty that day, carefully examined the case 
and prescribed the sulphate of quinia. This medicine, continued a few days, 



CAUSES. 613 

relieved the symptoms, but every four to six weeks, for more than a year, the 
febrile attacks returned, and were uniformly relieved by the same medicine. In 
other respects the patient had the usual health. 

On or about February 1, 1878, the nurse noticed that Charles had what she 
designated " spells of trembling," in which he seemed excited and feverish, and 
which were sometimes attended by or followed by perspiration. In the course 
of another week the irregular muscular movements became more marked and 
constant, and they increased in severity till near the time of the admission of 
the patient into the asylum, about March 1st. The nurse had noticed in Feb- 
ruary slowness and some difficulty of micturition, and Dr. Reid examined him 
with a catheter for calculus, and also his prepuce for any source of irritation, but 
nothing abnormal was discovered, either in the condition of the bladder or the 
external organs. In the latter part of April the chorea had become so severe 
that irregular muscular action occurred in all the limbs and in the muscles of 
the eyes, .producing such grimaces and contortions, with strabismus, that the 
woman with whom he was boarding became alarmed, and returned him to the 
asylum, stating that he had become crazy. 

On March 12th my attention was first called to this child, when I made the 
following entry in my note-book: Family history unknown; no history of rheu- 
matism in patient's case; he may or may not have had it; heart sounds normal; 
pulse 104 ; all the limbs and the muscles of the face, eyes, and eyelids involved in 
choreic movements, which continue constantly except during sleep. The patient 
cannot walk or stand without support ; appetite good, apparently better than in 
health, for he eats every kind of food handed to him, and carries the food with 
his own hand to his mouth, although these movements are very irregular and 
jerking. Three drops of Fowler's solution ordered after each meal. 

March 17th. — Condition not much changed, but perhaps slight improvement; 
in addition to other choreic movements the eyes twitch spasmodically ; pulse 84, 
temperature 98 J°; bowels irregular; no cough; appetite good. Increase medi- 
cine to five drops. 

30th. — The urine examined since the last record was found very pale and abun- 
dant ; its specific gravity low, 1004, without albumen. When an equal quantity 
of nitric acid was added to it, after twelve hours crystals of nitrate of urea occu- 
pied about one-half of the volume of the urine. The patient's sleep is quiet, but 
the choreic movements recommence as soon as he awakens, but in a milder form ; 
is able to walk without support, but with unsteady gait. My term of service 
ended March 31st. On the following day laryngo-tracheitis was suddenly devel- 
oped, ending fatally in forty-eight hours at the age of two years five and a half 
months. 

Autopsy, April 4th, — Slight oedema about the aperture of the glottis; general 
and intense redness of mucous membrane of larynx, trachea, and bronchial tubes ; 
as far as they can be traced, posterior portions of lungs greatly congested. The 
heart, lungs, brain with one eye attached to it by optic nerve, and the entire spi- 
nal cord were sent to Prof. Francis Delafield, for microscopic examination. They 
were, as soon as removed, placed in a solution of bichromate of potassium. The 
following is a brief statement of the examination which was made : 

Microscopic Appearances. By Prof. Francis Delafield. — Brain presented no 
change apparent to the naked eye except a considerable degree of congestion. 
It was hardened in bichromate of potassium and chromic acid. Minute exami- 
nation of the convolutions of the brain, the large ganglia, the cerebellum, the 
pons Varolii, and the medulla oblongata showed nothing except a uniform filling 
of the vessels with blood, as if they were injected. There were no apoplexies, 
no changes in the walls of the vessels. 

Spinal cord appeared to be entirely normal. 

The Heart. — The auricles and ventricles were of normal size. The aortic 
valves were atheromatous and somewhat rigid ; the mitral valves were thickened 
and insufficient ; the endocardium of the left ventricle was thickened. 

The Lungs. — The capillaries in the walls of the air-vesicles were dilated, and 
there was an increase of epithelial cells within the air-vesicles. 

In this case there seemed to be no lesion associated with the chorea except 
the organic disease of the heart and the changes in the lungs secondary to this 
condition of the heart. 

The above microscopic examination was made with sufficient minuteness, and 



614 CHOREA. 

it is seen that no emboli were discovered and no lesion of the cerebro-spinal axis 
except congestion, which was attributable to the mode of death — namely, by 
obstructed respiration. Moreover, it will be recollected that there were no car- 
diac bruits, and apparently not sufficient roughness of the edge or surface of the 
valves to cause precipitation of fibrin, which would be necessary in order that 
emboli should form. 

Fright. — A not infrequent cause of chorea is sudden and profound emo- 
tion, especially fright. All statistics give fright as the cause of a certain 
proportion of cases, though there are usually other potential co-operating 
causes, as anaemia or valvular disease. Fright was stated as the cause of 
chorea in 31 of the 100 cases occurring in Guy's Hospital reported by 
Hughes, or nearly 1 in 3. But the statistics of other observers do not give 
so large a proportion of cases originating in this way. Chorea may commence 
within a few hours after the fright or not till the lapse of several days (eight 
or ten). If several weeks have passed since the fright, as in some reported 
cases, the chorea is probably due to other causes. In rare instances chorea 
is said to have been caused by sudden and excessive joy. 

Imitation. — Under unusual circumstances, especially in a state of great 
mental excitement, imitation has been known to cause a form of chorea. 
Hecker describes an epidemic of it occurring in the Middle Ages and spread- 
ing through villages. In modern times it is rare that chorea originates from 
this cause, nevertheless occasional examples have been recorded. 

But the disease which occurs from imitation differs from the ordinary form 
and has been termed chorea major, while the chorea which is the subject of 
this article is sometimes designated, in contradistinction, chorea minor. 

In chorea major the patient leaps, dances, or whirls like a top. It has its 
origin commonly in religious excitement, and spreads by imitation almost in 
the manner of an infectious disease. The epidemic of the Middle Ages was 
a chorea major. I have not been able to find any account of cases spreading 
by imitation in modern times which were not examples of the same form of 
chorea. Thus in the Edinhtirgli Journal of Medicine and Surgery^ for July, 
1839, there is a clear description of chorea major occurring successively in 
five children in the same family. Dr. Dewar, the attending physician, states 
that one of the children whom he was called to see was sitting near the fire- 
place, when her head dropped on her chest and she appeared to doze some 
minutes. In the mean time the respiration became a little accelerated, the 
face altered and flushed, the eyes wild. In less than one minute she bounded 
from one extremity of the apartment to the other, leaping over chairs, a chest, 
and then throwing herself upon the floor ; she attempted to stand upon her 
head, rolled upon the floor, and then, rising, ran with extreme swiftness in 
the room, till she finally fell again upon the floor, where she remained motion- 
less some minutes. Then, recovering, she noticed those who surrounded her, 
and asked of her sister a toy which she had allowed to fall. The whole par- 
oxysm lasted twenty minutes. 

Obviously, the symptoms of chorea major difl"er materially from those of 
chorea minor, and it is a question whether it should have the same generic 
name. It is a curious and interesting disease in its psychical and patholog- 
ical aspect, but it is so rare in modern times that a knowledge of it is of 
little practical importance. 

Intestinal Irritation. — In rare instances intestinal worms cause chorea, 
though in these cases there have usually been some co-operating causes. 

The following is an example related by Mr. Ogle:^ "Ellen L , nine 

years old, had been under treatment about a month with chorea, rheuma- 
tism, and worms. She had hot slept in four days, and there was constant 
^ Land. Medico-Chir. Rev.. Jan., 1868. 



ANATOMICAL CHARACTERS. 615 

spasmodic movement of the body and face. Her general condition was very 
unpromising. As she had passed portions of a tape-worm at intervals during 
the last three months, one drachm of the oleum filicis maris was administered 
in mucilage, which caused the expulsion of the entire worm. From that time 
she fully and rapidly recovered from the chorea, though a mitral murmur 
remained." 

Lesions of Brain and Spinal Cord. — Although we reject the theory 
that cerebral emboli are the common cause of chorea, and believe that in a 
large majority of cases there are no cerebro-spinal lesions, nevertheless 
experiments and also occasional cases establish the fact that if not true 
chorea, at least choreiform movements now and then result from a struc- 
tural affection of the nervous centres. 

Experiments on certain of the lower animals demonstrate that irregular 
muscular movements may be produced by traumatic injury of certain por- 
tions of the cerebro-spinal axis, as the corpora quadrigemina, crura cerebri, 
pons Varolii, crura cerebelli, thalami optici, parts of the medulla oblongata, 
and the upper portion of the spinal cord. Pressure on the projecting part of 
the medulla oblongata of an acephalous monster also causes convulsive move- 
ments. At the meeting of the New York Academy of Medicine, April 20, 
1871, Professor Post related the case of a child who was struck over the 
occiput with a billet of wood, and chorea followed, due. in all probability, to 
the injury of the brain which resulted. 

If irregular muscular movements, choreic or choreiform, result from trau- 
matic injury of certain portions of the nervous centres, may they not also 
occasionally occur from lesions of the same parts produced by disease ? Sir 
Benjamin Brodie^ relates the case of a choreic girl dying in St. Greorge's 
Hospital, in whom, after a careful post-mortem examination, the only morbid 
appearance observed was a tumor the size of a hazelnut connected with the 
pineal gland. Dr. Broadbent'^ described another case before the London 
Pathological Society in which a tumor was found arising from the centre of 
the spinal cord ; and Chambers one in which tubercles were imbedded in the 
cord. Bomberg quotes from Frerichs a case in which the medulla oblongata 
was pressed upon by an enlarged odontoid process; and Dr. Aitkin-^ one in 
which the specific gravity of the thalamus opticus and corpus striatum was 
greater on one side than on the other. Billiet and Barthez relate other similar 
cases, and they remark : " We may conclude from these different cases that 
there exist two species of chorea — the one essentially a simple neurosis, while 
the other depends on an alteration of the encephalo-rachidian system. In a 
word, it is of chorea as of convulsions, that it is sometimes idiopathic, some- 
times symptomatic." Still, the cases in which it is symptomatic are so few 
that it is proper to consider chorea, as it ordinarily occurs, one of the neu- 
roses until the microscope detects some anatomical cause in the cerebro-spinal 
system of which we are now ignorant. 

Anatomical Oharacters. — We have seen that chorea has no constant 
anatomical characters. Lesions which probably sustain a causal relation to 
the disordered muscular action are sometimes present, and others are some- 
times observed which are neither a cause nor a result, their presence being a 
coincidence. But there are two lesions wdiich, though often absent, have 
been observed in so large a proportion of fatal cases that they are justly 
regarded as an occasional result when chorea is severe. Dr. Hughes of Lon- 
don collected records of the post-mortem appearances of 14 cases, with the 
following result as regards the cerebro-spinal axis : Brain, 1-4 cases ; healthy, 

^ London Lancet, Dec. 19, 1840. 

^ Transactions London Pathological Society, vol. xiii. p. 246. 

^ Glasgow Medical Journcd, vol. i. 



616 . CHOREA. 

4 cases ; only congested, 3 cases ; softened in part or entirely, 6 cases (some 
of these 6 also congested). In some of the 14 cases those occasional results 
of congestion — to wit, transudation of serum and extravasation of blood in 
greater or less quantity — were also observed. Spinal cord : healthy, 3 cases ; 
congested, 2 cases (one slightly, in the other the engorged vessels were large 
and numerous) ; softening in medulla oblongata, 1 case ; softening opposite 
fourth and fifth vertebrae, 12 cases. In 1 there was soft, in another firm, adhe- 
sion of the spinal meninges, and in 1 it is stated that the rachidian fluid was 
opaque. Of 16 fatal cases of chorea occurring in St. George's Hospital, 
''congestion (more or less complete) of the nervous centres (brain or spinal 
cord, or both) was met with in 6 cases." Softening of certain parts of the 
brain was observed in 1 case, and of the spinal cord in another.* Other sta- 
tistics of the anatomical character of fatal chorea correspond, in the main, 
with those of Hughes and Ogle. The lesions observed by them are probably 
not present in ordinary cases, occurring only when the choreic movements are 
so severe that the patient is deprived of needed repose and the important 
functions of the economy, as circulation and nutrition, are seriously dis- 
turbed. 

The post-mortem examination of other parts besides the cerebro-spinal 
axis furnishes a negative result, if we except such affections as have been 
ascertained to act as causes of chorea. What portion of the nervous centre 
is chiefly involved in chorea is uncertain. Some, as Sir Benjamin C. Brodie,'^ 
consider chorea a disease of the nervous system generally, while others have 
attributed it to disease or disorder of a certain part, as the corpus striatum, 
cerebellum, etc. Finally, it is stated that in late experiments on choreic dogs 
the movements do not cease when the spinal cord is severed from the brain, 
nor also on division of the posterior roots of the spinal nerves.^ In these 
cases, therefore, the part of the axis which is in fault would appear to be 
solely the spinal cord. 

Symptoms. — Chorea is partial or general. It is partial when it affects a 
few muscles or groups of muscles, as those of one arm, the face or neck, or 
of one eye. It is designated general when all the limbs and certain of the 
muscles of the face and trunk are involved. Statistics show that partial 
chorea occurs more frequently on the left than on the right side, and in gen- 
eral chorea the movements on the left side usually predominate. The com- 
mencement is in most cases gradual. Even when finally chorea becomes 
general, certain muscles only are affected in the commencement in ordinary 
cases. The child in whom this disease is about to begin is observed to be 
fretful and impatient from slight causes, and the irregular muscular action 
is sometimes misunderstood by the parents, who reprimand him for his sup- 
posed fidgety habit. In exceptional instances, especially when the cause is a 
sudden and profound emotion, the commencement is abrupt and the disease 
is severe and general from the first. 

In a majority of cases the muscles which are primarily affected are those 
of the face, neck, fingers, or hand on the left side. Sydenham erred, unless 
the clinical history of chorea has changed during the last two centuries, when 
he stated as the common fact that a tottering gait is its first manifestation, 
but now and then such a case does occur. Whenever choreic movements 
appear other muscles besides those first affected are soon involved, so that in 
the course of a few weeks, sometimes of a few days, all the muscles that 
participate are engaged. 

* Ogle: Brit, and For. Medicn-Chir. Rev., Jan., 1868. 
2 London Lancet, Dec. 19, 1840. 

^ Legros et Onimus: Kech. sur les raoiivements choreiformes du Chien, Acad, des 
Sci., 9 Mai, 1870, Lyons Med. Jour., June 5, 1870. 



SYMPTOiMS. 617 

A muscle affected by chorea alternately contracts and relaxes, but less 
forcibly and rapidly than in eclampsia, and the movement is partly controlled 
by volition. This produces an unsteady and tremulous action of the part, 
whether a limb, the neck, or the face, which at once arrests attention and 
indicates the nature of the disease. The result is similar, as regards the 
muscular action, whether the patient wills a movement or attempts to control 
those which chorea produces. 

If the case be of ordinary severity, the movements continue with but 
momentary intermissions, except during sleep, when they ordinarily cease. 
In grave cases patients are often deprived of the proper amount of sleep in 
consequence of the severity and persistence of the muscular action, and in 
exceptional instances, especially when the result is fatal, the movements con- 
tinue in sleep, but the sleep is not sound and is frequently interrupted. In 
profound sleep the muscles are always in repose. 

The older writers have left us graphic descriptions of those diseases which 
have striking external manifestations, though often with somewhat of exag- 
geration. Sydenham says of chorea : " The patient cannot keep it (his hand) 
a moment in the same place ; whether he lay it upon his breast or any other 
part of his body, do what he may, it will be jerked elsewhere convulsively. 
If any vessel filled with drink be put into his hand, before it reaches his 
mouth he will exhibit a thousand gesticulations, like a mountebank. He 
holds the cup out straight, as if to move it to his mouth, but has his hand 
carried elsewhere by sudden jerks. Then, perhaps, he contrives to bring it 
to his mouth, and if so, he will drink the liquid off at a gulp, just as if he 
were trying to amuse the spectators by his antics." 

In severe general chorea a similar description is applicable to the move- 
ments of the legs and features. Grimaces and distortions of the features 
occur, while the gait is halting and unsteady, or it is impossible to walk, and 
the patient lies or sits. The speech is slow, thick, and indistinct in conse- 
quence of the muscles of the tongue and larynx becoming engaged, and even 
mastication and deglutition are rendered difficult. The imperfect speech in 
chorea is attributed partly, however, to the mental state in severe protracted 
cases. Chorea, except when mild, is accompanied by other symptoms refer- 
able to the nervous system. More or less impairment of the mental faculties 
occurs in chronic cases when severe, exhibiting itself in dulness or apathy. 
The countenance sometimes presents in aggravated cases almost the appear- 
ance of idiocy. The muscles, instead of becoming hypertrophied and more 
powerful by their frequent contraction, grow softer, more flabby, and weaker. 
Indeed, a partial paralysis sometimes results, so that a degree of numbness is 
experienced in the affected part and the limb when raised cannot be sustained. 
Pain is not a symptom of chorea, but fugitive rheumatic or neuralgic pains 
are sometimes experienced. Derangement of the digestive function, exhibited 
by a poor or capricious appetite, constipation, etc., are common. 

£n rare instances chorea affects the respiratory muscles so as to produce a 
peculiar involuntary barking or squeaking voice by the forcible expulsion of 
air over the tense vocal cords. In a case treated by Dr. L. C. Gray in the 
N. Y. Polyclinic the patient, a boy of fifteen years, had been choreic since 
his seventh year, and chorea in its usual form had continued one year when 
the barking sound commenced, and this has continued until the present time. 
Dr. French of Brooklyn also treated a similar case, having the following his- 
tory : A boy of nine years had choreic twitchings of the facial muscles at 
the age of five years. After continuing several months, they ceased during 
an entire winter, after which the peculiar sound of the voice, resembling the 
squeak of a young turkey, commenced. It occurred at the beginning, middle, 
or end of respiration. It alternated with choreic movements of other parts 



618 CHOREA. 

of the system, so that when they ceased it returned. By the laryngoscope 
the irregular action of the vocal cords was observed, but the expiratory mus- 
cles of the chest were also involved, so as to produce the peculiar sound by 
the forcible expulsion of air. In Dr. French's case these vocal sounds ceased, 
except at rare intervals, after three months of medicinal treatment.^ 

The urine of choreic patients has been examined by Drs. Walsh, Ford, 
Bence Jones, Handfield Jones, RadclifFe, and others, and its elements have 
been found in most cases to vary from their normal quantity. Dr. Handj&eld 
Jones ^ read a paper before the Clinical Society of London in 1871 on two 
cases of chorea in which he had made careful chemical analysis of the urine, 
with the following result : During the height of the disease the amount of 
the urine was much in excess of what it was when the disease had ceased; 
the urea excreted during the choreic period was in excess, as was also the 
phosphoric acid excreted when the choreic symptoms were at their maximum, 
but the quantity of this acid was less than the average during convales- 
cence ; a moderate amount of uric acid during the disease was also observed, 
but none upon recovery. 

Prognosis ; Course. — Chorea, though obstinate and often incurable in 
adults, usually terminates favorably in children in two to four months. 
Bouchut considers its ordinary duration at from thirty to fifty days, which is 
certainly shorter than the average duration in this country, except when the 
disease is materially abridged by treatment. The same author states that it 
may continue only a few days, as he has observed in cases which occurred 
during convalescence from scarlet fever. But tremulousness of the muscles, 
occurring in the state of weakness following a grave disease and abating as 
the general health is restored, I should not consider as properly choreic, any 
more than that occurring from over-fatigue. As the choreic movements 
gradually increase in the initial period till a certain maximum is reached, so 
their decline is gradual. Temporary variations also occur throughout the 
disease as regards the extent of the movements, which are aggravated by 
mental excitement, bodily fatigue, certain functional derangements, especially 
of digestion, and sometimes from causes which are not apparent. 

Though, as a rule, chorea in children ordinarily terminates favorably 
under different and even injurious modes of treatment, there are exceptional 
cases. Romberg relates the history of a patient who died at the age of 
seventy -six years, having had chorea since the age of six years. In chorea 
limited to a few muscles or a group of muscles the prognosis is more doubt- 
ful than when it affects a large number, since in the former case the cause is 
more likely to be some lesion of the cerebro-spinal axis. Thus, chorea 
involving only certain muscles of the neck or of the eyes is sometimes due 
to this cause, and is then very obstinate. 

Again, observations demonstrate that chorea, when at first, in all prob- 
ability, strictly a neurosis, but of a protracted and grave character, may give 
rise to a central organic disease. This is the course of most of the fatal 
cases, congestion, softening, or other lesion occurring over a greater or less 
extent of the nervous centres. Radcliffe has known cerebral meningitis to 
supervene in two instances. With the occurrence of a lesion of the cerebro- 
spinal axis new symptoms arise, such as headache, convulsions, delirium," and 
paralysis, and the choreic movements cease or continue according to the 
nature of the lesion. 

Chorea, like certain other diseases either of a nervous character or having 
a nervous element, is more or less modified by intercurrent inflammatory and 
febrile affections. The oft-quoted expression from Hippocrates, febris acce- 
dens solvit spasmos, observations show to be founded in fact, the most frequent 

1 N. Y. Med. Record, Dec. 15, 1883 : Dr. Chapin. ^ London Lancet, July, 1871. 



DIAG^^OSIS—TEEAT^IENT. Q19 

example of which occurs in pertussis. In chorea the movements, as a rule, 
are either rendered milder or they cease as long as the febrile excitement con- 
tinues ; but there are exceptions, and the subsequent course of the disease is 
not modified. 

Diagnosis. — This is not difficult in ordinary eases. The irregular move- 
ments with consciousness preserved enable us to make a diagnosis at sight. 
In its commencement and when it continues in an unusually mild form chorea 
may be overlooked by the ph3^sician, as it often is by the parents, the move- 
ments being attributed to a fidgety habit ; but medical advice is seldom sought 
till the movements are so pronounced that it is impossible to err, except 
through gross ignorance or carelessness. 

It is important to determine when chorea merges in an organic disease, 
and also whether there is a local cause of the chorea. A careful and intelli- 
gent study of the symptoms and history of the case is requisite in order to a 
correct diagnosis in these particulars. 

Treatment. — Regimenal — As chorea in a large proportion of cases 
occurs in a state of ansemia, and the vital forces are ordinarily more or less 
reduced, obviously the regimen should be such as invigorates the system. 
Fresh air and outdoor exercise, active or passive according to circumstances, 
with the avoidance of undue excitement, are requisite, and the diet should be 
nutritious, but plain and unirritating. The various functions should be pre- 
served so far as possible in their normal state. In exceptional instances, 
when the choreic movements are violent, the patient should lie in bed, and the 
muscular action, if so constant and excessive as to deprive him of the requisite 
sleep, should be restrained by light and well-padded splints. 

Medicinal. — Sometimes among the co-operating causes is one of a local 
nature which is susceptible of removal, as a carious and painful tooth, intes- 
tinal worms, etc., and measures calculated to efi'ect this are obviously 
required. Allusion has already been made to a case in which the employ- 
ment of the oleo-resina filicis and the expulsion of a tape-worm effected a 
speedy cure. 

The remedy which has been most employed in chorea, and which in con- 
sequence of the anaemia is plainly indicated in a large proportion of cases, 
is iron. It does not interfere with the employment of other remedies which 
have a more specific effect. Nearly all the ferruginous preparations have 
been prescribed in different cases with benefit. Radcliffe gives the preference 
to the iodide of iron, believing that iodine as well as iron exerts a curative 
influence. I have prescribed the ammonio-citrate, since it is easy of adminis- 
tration in simple syrup and is well tolerated ; but I now prefer liquor ferri 
peptonati, recently introduced from G-ermany. It should be given in doses 
of one to three teaspoonfuls three times daily. 

But iron must not be regarded as the main remedy, but rather as an 
adjuvant. Observations during the last few years in both continents have 
more and more established the claims of arsenic to be regarded as the most 
efficacious of all medicinal agents in the treatment of chorea. Properly 
administered, it abridges the duration of this disease more certainly than any 
other agent, and within a few days begins to modify the choreic movements 
in the severest cases. It is conveniently given in the form of Fowler's solu- 
tion. It is better tolerated by children than by adults, and should be admin- 
istered to them in a larger proportionate dose. A child of eight years can 
take five drops, diluted in water, three times daily after eating, and the dose 
may be increased, if needed, to eight, ten, twelve, or even fifteen drops. I 
seldom observe any gastric irritability or other unpleasant effect from its use 
when it is administered largely diluted and after the meals, but if such occur, 
it should, of course, be suspended for a time. 



620 CHOREA. 

While not hesitating to recommend iron and arsenic as superior to all 
other medicines in the treatment of chorea, it is not proper to ignore the 
opinions of other members of our profession who have had ample experience 
and recommend other agents instead. 

Trousseau gave the preference to strychnine, increasing the doses in some 
cases until it began to produce its poisonous effects. 

Professor Hammond ^ says : " My main reliance is on strychnia, which, I 
think, should be given in gradually increasing doses, somewhat after the 
manner recommended by Trousseau This plan of treatment cer- 
tainly shortens the duration of the disease very materially, and causes great 
improvement in the general health of the patient. Sometimes the effect is 
so well marked and is so immediate that it is not necessary to increase the 
doses to the extent of causing muscular cramps, but generally the full thera- 
peutical effect of the drug is not obtained till the calf of the leg or the nucha 
has slight tonic spasm. I have never seen the slightest ill-consequence 
follow this mode of treatment, and the doses are increased so gradually that 
with careful watching danger need not be apprehended." Dr. Hammond has 
treated thirty-two children with this agent without a single failure. 

But as chorea terminates favorably with smaller and safe doses, even if 
the time required be longer, it does not seem proper to recommend its em- 
ployment to the extent of producing physiological effects for general prac- 
tice. Bouchut, speaking upon this point, says : " But with these precautions 
strychnia is extremely dangerous, for I have seen at the Hopital des Enfants 
Malades a young girl of thirteen years die in tetanus " produced by an 
increased dose of this drug (article on Chorea). Dr. West, in his Lumleian 
Lectures, also says : " I have seen one instance in which its employment, while 
it failed to benefit a somewhat severe case of chorea, was followed by two attacks 
of violent tetanic convulsions, which nearly proved fatal ;" and he adds : " The 
twitching of the limbs of itself prevents our becoming aware of the dose 
being excessive." Therefore, Dr. West does not favor the employment of 
this agent. Still, any agent may be given in an overdose, and it is not 
difiicult to prescribe strychnia in a dose which may be efficient, and yet safe 
for children, at the age at which chorea ordinarily occurs. 

I have employed bromide of potassium in a few cases, but with so little 
benefit that I am not inclined to continue its use for this disease. Others 
have not been more successful. However efficacious the bromide may be in 
epilepsy, it does not appear to be a remedy for chorea. 

Cimicifuga, first employed by Jesse Young of this country, is highly 
esteemed by Philadelphia physicians in the treatment of chorea. I have 
employed the fluid extract in doses of half a drachm, increased to one 
drachm, for a child from six to ten years of age, and, though it benefits 
some cases, it has no appreciable effect either in moderating the movements 
or abridging the duration of others. 

Ether, asafcetida, valerian, musk, the oxide and sulphate of zinc, tur- 
pentine, tartar emetic, opium, and numerous other remedies have been 
recommended, and some of them have seemed useful in certain cases. In 
this city sulphate of zinc has been frequently employed as a remedy for 
chorea, and in gradually increasing doses till more than twenty grains were 
administered three times daily ; but it has not appeared, so far as I have 
been able to ascertain, to exert any marked influence either on the severity 
or duration of the choreic movements. Justice, however, requires us to 
state that Dr. West, who has written recently on the nervous diseases of 
children, thinks that it has been beneficial in certain cases in which he has 
employed it, and he regards it on the whole as the best remedy. 
^ Diseases of the Nervous System, page 617. 



PARALYSIS. 621 

Radcliife, who has had ample experience in the treatment of nervous 
affections, writes : " In an ordinary case of chorea the plan of treatment 
which I have now adopted as a rule for some time is to give cod-liver oil in 
conjunction with hypophosphite of soda, making the draught containing the 
latter salt the vehicle for the administration of the cod-liver oil." Some- 
times camphor or the sesquicarbonate of ammonia is added. Of more than 
thirty cases treated in this way, the average duration was under three weeks. 
Radcliffe began to prescribe these remedies on theoretical grounds, believing 
that phosphorus and cod-liver oil were required to restore "nerve-tone," and 
the result of this treatment has certainly been such as to commend it to the 
profession. To children he gives from five to eight grains of the hypophos- 
phite of sodium three times daily. 

In those severe cases, in which choreic movements prevent the proper 
amount of sleep, a moderate dose of hydrate of chloral may occasionally be 
advantageously administered. 

Electricity has been many times employed in the treatment of chorea, 
and though some, chiefly electricians, believe that it has a curative effect, 
others, and the majority, fail to see any material benefit from its use. 

Cold general baths, the shower-bath, frictions along the spine, etc. have 
been employed ; but the local treatment which has so far been most success- 
ful, and which promises to supersede all other local measures, consists in the 
application of ether spray over the spine. About two ounces of ether are 
employed at each sitting, the spray being applied from an atomizer up and 
down the whole length of the spine if the chorea be general. The opera- 
tion, which occupies from ten to fifteen minutes, should be repeated daily 
or every second day. A considerable number of cases have been reported 
in which the spray has apparently had a good effect in controlling the dis- 
ease. But I repeat my belief, from the large number of cases seen in the 
Bureau for the Relief of the Out-door Poor, that the arsenical and ferrugi- 
nous treatment gives more satisfaction than any or all other measures. 



CHAPTER Xy. 

PARALYSIS. 

Paralysis in young children, especially infants, is in most instances due 
to causes which seldom produce it in adults. The principal cause of it in the 
adult — namely, cerebral apoplexy — is indeed rare in children. Paralysis in 
children has the following recognized causes : 1st. A change in the blood, 
not fully understood, induced by certain grave diseases, as diphtheria, typhoid 
fever, measles, scarlet fever, etc. 2d. Reflex influence. The function of 
some part of the system is in some way disturbed, and paralysis occurs in 
certain muscles, perhaps at a distance from the cause, and it disappears when 
that cause is removed, unless it have continued too long. The only rational 
explanation is found in the fact of a continuous connection between the local 
cause and the paralyzed muscles through the afferent and efferent nerves and 
the nervous centres. 3d. Compression or injury of a nerve-trunk. These 
cases are rare. Pressing of the portio dura by the blades of forceps during 
birth, described in the next chapter, is an example. 4th. An anatomical 
alteration in the muscular fibres, the nerves and nervous centres remaining 
unaffected. This has been designated myogenic paralysis. This form of 



622 PABALYSIS. 

paralysis is probably often of a rheumatic nature. Paralysis of the face or 
other portions of the surface, which sometimes occurs in children and adults 
from prolonged exposure to cold winds, is of this nature. 5th. Some anatom- 
ical change in the nervous centres, as congestion, hemorrhage, inflammation, 
emboli, compression and laceration of brain, whether by tumors, inflamma- 
tory products, or other causes, etc. If there be hemiplegia, the presumption 
is that the disease causing it is cerebral ; if paraplegia, that it is spinal. 
The following is an interesting example of hemiplegia. The case was related 
by me, and the specimen presented to the New York Pathological Society : 

Case. — Maggie , aged two years and eight months, was admitted into the 

New York Foundling Asylum about the 1st of September, 1874. She seemed to 
be in good health and was plump and well-developed, and her mother stated 
that she had had no serious sickness. After her admission she continued well, 
having the usual appetite, amusing herself through the day, and presenting no 
symptoms to attract attention till December 6th. On the evening of December 
5th she ate her supper as usual, and was placed in her crib, apparently in perfect 
health. At 3 A. M. the sister who was in charge of the ward found her in severe 
general eclampsia. Immediately, in addition to the usual local treatment, she 
administered five grains of bromide of potassium, and this was repeated at inter- 
vals till six or seven doses were administered. Nevertheless, the spasmodic 
movements continued, with more or less violence, till Ih P. M., and in the muscles 
of the leg somewhat longer. 

On my arrival at the asylum, at about 6 P. M., I found her lying quietly, 
rather stupid, but easily aroused. Her vision was evidently good, and she was 
conscious ; the pupils responded to light and the direction of the eyes was nor- 
mal ; pulse 104, no cough, and respiration natural ; temperature, as ascertained 
by the thermometer in the axilla, also normal. There was no apparent paralysis 
of the muscles of the face, but the right arm and leg were paralyzed, though the 
paralysis was not complete. The great toe flexed on tickling the sole of the foot, 
but the foot itself had little or no motion, and on my attempting to flex the leg, 
which was extended, some rigidity of the muscles was observed. At times the 
patient produced slight movement of the thigh upon the trunk. The muscles of 
the right upper extremity were more flaccid than those of the leg, and motion 
of the forearm was totally lost, while a little movement remained of the arm on 
the trunk. During the two or three days succeeding the convulsions sensation in 
the right limbs did not appear to be entirely lost, though greatly enfeebled. 
Subsequently paralysis in the right limbs, both of the nerves of sensation and 
motion, was nearly or quite total, and continued so till death. Nevertheless, 
tickling the sole of the foot caused some movement of the great toe. On the left 
side sensation and motion were perfect. 

The record of December 9th runs : Has vomiting to-day for the first time ; 
apparently sees well, and appearance of the eyes normal ; has no retraction of 
head or rigidity of muscles of neck or along the spine ; pulse 96, temperature in 
the axilla normal ; lies quiet and with eyes shut ; is stupid, and not fretful when 
aroused ; the bowels move regularly. 

December 11th, continues to vomit at intervals; pulse 68. Dec. 16th, pulse 
80, temperature 100° ; vomited once yesterday, none to-day ; lies in a constant 
doze; takes bromide of potassium gr. iv three times daily. Dec. 18th, moans at 
times, as if in pain ; pulse 180, temperature 100° ; takes the bromide gr. iv every 
four hours. 

Dec. 19th, pulse 180, temperature 103° ; she has convergent strabismus, and 
the eyes have a wild, almost insane look, but she sees, grasping hurriedly the 
percussion hammer presented toward her; paralysis of nerves of motion and sen- 
sation in the right extremities nearly complete ; slight movement is still produced 
in the great toe by titillation ; the vomiting has ceased ; tongue covered with a 
thick fur ; movements of the bowels pretty regular ; has a slight cough, such as is 
common in cerebral disease. 

Dec. 22d, lies quietly on her side in perpetual slumber, with eyes constantly 
shut; pulse 118, temperature 101^°; the bowels still move nearly normally; the 
pupils, exposed to the light, are seen to oscillate, but are constantly more dilated 
than in health ; the urine passes freely ; circumscribed flushing of the features 



FAEALYSIS. 623 

at intervals ; a rash like lichen over abdomen and chest, possibly due to the 
large quantity of bromide of potassium administered. 24th, pulse intermittent ; 
pupils dilated. 

Dec, 25th, died in profound stupor to-day, having lived nineteen days from the 
commencement of the malady. 

Autopsij. — About thirty hours after death, weather cool. On removing the 
calvarium and dura mater, which presented no unusual appearance, the vessels 
of the pia mater were found rather more injected than usual, but not more so 
than we sometimes observe in those who die of diseases which do not involve the 
brain. The cerebro-spinal fluid was scanty and the surface of the brain rather 
dry. The vertex of the left hemisphere was unusually prominent, rising perhaps 
half an inch higher than that on the opposite side. At the highest point, which 
was about one and a Jialf inches from the median line, was a circular yellowish 
spot upon the surface of the brain about one and a half inches in diameter. 
Pressure upon this spot, made lightly so as not to produce rupture, communicated 
the sensation of a large cavity underneath filled with liquid and approaching to 
within two or three lines of the surface. There was no adhesion or exudation 
over this spot, and the surface of the brain appeared entirely normal, except a 
little cloudiness of the pia mater over a space which could be covered by a five- 
cent piece, a little posterior to the optic commissure. The incised surface of the 
brain at a distance from the abscess showed no increase of vascularity. The 
right hemisphere appeared in every way normal, except that its lateral ventricle 
was filled with pus, but not distended. 

On the left side, occupying the centre of the hemisphere, was an abscess as 
large as the fist of a child of two years, extending from within two or three lines 
of the vertex, where its site corresponded with the yellow spot on the surface of 
the brain, to the roof of the lateral ventricle. Through this roof the abscess had 
burst, filling and distending the ventricle with pus, and thence making its way 
into the lateral ventricle of the opposite hemisphere. The whole amount of pus 
contained in the abscess and the two ventricles was perhaps two ounces. The 
w^alls of the left lateral ventricle were much softened, the upper part of the 
corpus striatum and thalamus opticus being nearly diffluent ; the walls of the 
right lateral ventricle were slightly softened, iDUt to less depth. The parietes of 
the abscess, which extended from the roof of the ventricle to the vertex, as 
already stated, were indurated to the depth of one and a half lines in consequence 
of proliferation of the connective tissue, except at the base of the abscess, which 
corresponded with the roof of the ventricle, where softening had occurred. The 
spinal cord, so far as it could be examined from the cranial cavity, had the usual 
vascularity and seemed nearly or quite normal. 

The cause of encephalitis from which the abscess resulted was obscure. This 
inflammation, so far as can be ascertained, was idiopathic, which is known to be 
a rare disease. There was no history of otitis, which is one of the most frequent 
causes of cerebral abscess, nor of heart disease, so as to produce embolism. It 
seems probable, since there was no fever till about the fourth day after the con- 
vulsions, that an abscess had primarily occurred in the hemisphere between the 
roof of the ventricle and the vertex, probably weeks previously. The bursting 
of this into the lateral ventricles, and the constitutional disturbance, inflamma- 
tion, and softening to which this gave rise, aftbrd sufficient explanation of the 
history of the case after the commencement of the convulsions. 

Paralysis occurring as a symptom or sequel of some obvious local or gen- 
eral disease, as diphtheria, lesion of the nervous centres, etc.. and which may 
occur at any age. need not detain us. It is described in connection with the 
primary diseases on which it depends. 



624 POLIOMYELITIS ACUTA ANTERIOR. 



CHAPTER XVI. 

POLIOMYELITIS ACUTA ANTEEIOR. 

This form of paralysis occurs, with few exceptions, between the ages of 
six months and seven years. 

Symptoms. — The previous health of the patient is usually good. The 
paralysis does not always commence in the same manner. In a few instances 
it begins suddenly in the day-time when the child is apparently in perfect 
health. In others it begins abruptly, after sound sleep. The child goes to 
bed well, sleeps through the night, and awakens in the morning paralyzed. 
I have known it to occur in one instance after sleep in the middle of the day. 
In these cases there has sometimes been an exposure before the sleep to wind 
or rain or from sitting on a cold stone. But in the majority of cases the 
paralysis is preceded and accompanied by a very decided elevation of tem- 
perature, which comes on suddenly without appreciable cause, and after a 
few days the power of motion is found to be lost in one or more of the limbs. 
No symptom occurs during the fever indicative of disease of the brain : con- 
sciousness is retained, and the headache or apparent liability to convulsions 
is no greater than in other pathological states accompanied by an equal amount 
of fever. The paralysis is at its maximum in the commencement. Occur- 
ring as by a stroke, the full extent of the paralytic state is exhibited at once, 
and so far as there is any subsequent change it is an improvement as regards 
the number of muscles affected and the degree of the paralysis. Most fre- 
quently the muscles of one or both lower extremities are affected. Occa- 
sionally one of the upper extremities is also paralyzed in addition to the 
lower, but paralysis of an upper extremity is less in degree, and disappears 
sooner, than of the lower. The bladder and lower bowel remain unaffected, 
since only the muscles of volition are involved. Sensation is unimpaired in 
the affected limbs, and in the commencement there is even in some cases a 
state of hyperaesthesia (West). The fever which precedes and accompanies 
the paralysis in certain cases gradually abates, and in a few days nothing 
abnormal remains except the loss of power in the affected muscles. These 
muscles are flaccid and relaxed, so that the limb falls by its weight when 
unsupported, and they are usually free from pain. The number of muscles 
paralyzed varies greatly in different cases. Only one muscle or a single 
group of muscles may be affected, or, on the other hand, both the extensor 
and flexor muscles of two or more limbs may be paralyzed. In the opinion 
of Mr. Adams, the following table exhibits the groups of muscles and single 
muscles most frequently involved, and in the order stated : 

Groups. 

1. Extensors of toes and flexors of the foot. 

2. Extensors and supinators of the hand. 

3. Extensors of leg, and with them usually the first group. 

Single Muscles. 

1. Extensor longus digitorum of toes. 

2. Tibialis anticus. 

3. Deltoid. 

4. Sterno-mastoid. 



PROGNOSIS— ETIOLOGY. 625 

The following is an example of infantile paralysis as it not infrequently 

occurs when the result is favorable : A. K , German, female, aged three 

years and four months, fleshy ; had been in the habit of sitting on the ground 
near the house and on the door-sill. On July 2, 1871, she had a sound sleep 
in the afternoon, having been entirely well previously, and awoke trembling 
and with a high fever at 3j p. m. At 8 P. M., the febrile excitement con- 
tinuing, general clonic convulsions occurred, lasting about ten minutes. At 
this time I was called to see her, and found her face flushed, surface hot, and 
pulse about 130. Consciousness returned after the convulsion. Her intelli- 
gence was good, tongue moist and slightly furred, bowels rather constipated, 
and the urine freely passed. The fever continued two days, when it grad- 
ually and entirely abated, but before it ceased paralysis of the left lower 
extremity was observed. No weight at first could be sustained upon this 
limb, and it hung powerless when we endeavored to make her walk. The 
attempt caused her to cry, as if in pain, and pressing upon the thigh or 
moving it had the same eff"ect. The thigh of this limb appeared slightly 
swollen on inspection, but measurement did not indicate any notable enlarge- 
ment. The difference in circumference was not more that one-eighth to one- 
fourth of an inch. There was no appreciable increase of heat in the thigh 
over the general temperature of the body. Sensibility remained in every 
part of the limb, and the loss of power was not complete, for on the first 
day, as soon as the paralysis was observed, slight and imperfect movements 
could be produced by pinching the limb. In three weeks the use of the 
limb was fully restored by mildly stimulating liniments and simple medicines 
to regulate the bowels. The tenderness which was observed in this case is 
only occasionally present, and has been attributed to hyperaesthesia. 

Prognosis ; Progress. — The paralysis in nearly all cases soon begins to 
abate. The power of motion returns little by little, and whatever improve- 
ment occurs is permanent. There is no retrogression in the convalescence. 
The sooner improvement commences the more favorable is the prognosis. In 
the most favorable cases there is complete restoration in from three to four 
weeks. In other patients, while certain of the muscles regain the power of 
motion, other muscles, oftener those of the lower extremity than of the 
upper, do not recover their function, and, unless proper remedial measures be 
employed, and even with them in certain instances, atrophy soon commences. 
The temperature of the paralyzed limb falls three, five, or even eight degrees, 
and the amount of blood which circulates in it is diminished, so that the 
pulse of the limb is feebler and its vessels smaller than in health. With the 
atrophy the contractility of the muscular fibres by the electric current dimin- 
ishes, and in unfavorable cases after a time powerful induced and even pri- 
mary currents have no appreciable efi"ect. The nutrition of a paralyzed 
limb is always imperfect, and if the paralysis occur in a child its growth 
is retarded. Therefore, in cases of protracted or permanent infantile paral- 
ysis of one limb a disproportion occurs both in diameter and length between 
it and that on the opposite side. If the paralysis continue, the ligaments of 
the paralyzed limb become relaxed and lengthened. West mentions a case 
of paralysis of the deltoid in which the humero-scapular ligaments were so 
extended that the humerus dropped from the glenoid cavity, so as to increase 
the length of the limb three-fourths of an inch. In the paralysis of certain 
muscles of the lower extremity and continuance of the contractile power 
in others we have the conditions which give rise to club-feet, and accord- 
ingly this deformity is the common result of the paralysis when it is not 
cured. 

Etiology.— As this form of paralysis is not fatal, opportunity for post- 
mortem examination in a recent case seldom occurs. Hence the difiiculty in 

40 



626 POLIOMYELITIS ACUTA ANTERIOR. 

determining the exact anatomical change in the nervous system which pro- 
duces the paralysis. Medical literature contains records of a considerable 
number of cases in which autopsies have been made, but death occurred so 
long after the commencement of the paralysis, usually months or years, 
that it is difficult to determine whether lesions which have been observed 
were a cause or consequence. In a majority of these autopsies a spinal lesion 
of some sort was detected, but in some instances none could be discovered 

Mr. Adams in his treatise on club-foot relates a case in which the spinal 
cord, carefully examined, probably only with the naked eye, seemed normal. 
Robin examined the spinal cord microscopically in one case, but discovered 
nothing abnormal, and Elischer made autopsies in two cases of this paralysis 
in which death had occurred from variola, but with a negative result as 
regards the nervous system.^ The examinations by Robin and Elischer, 
since they were microscopic, have been justly regarded as important, and 
they have been related by writers in order to sustain the theory that 
infantile paralysis is peripheral and not centric. 

Very little was effected prior to 1863 in determining the cause or causes 
of this paralysis by post-mortem examinations, because the microscope was 
so little used, and because in most of the cases reported the clinical history 
or microscopic lesions were such as to show or to render it highly probable 
that the paralysis was not of the kind which we have been describing. 
Thus, Beraud reported a case in which tubercles were found in the spinal 
cord ; Hammond, a case in which a clot was found in the spinal cord ; and 
Jaccoud, one of spinal arachnitis with thickening of the meninges. Since 
I860, 17 autopsies have been recorded in which the spinal cord was carefully 
examined, and upon these we must chiefly rely for our data by which to 
determine what are the anatomical changes in the nervous system which 
probably cause this paralysis. The reader will find these cases tabulated 
in a lecture by E, C. Seguin, M. D.,^ and the most important of them nar- 
rated in a paper on infantile paralysis, showing great research, published by 
Dr. Mary Putnam Jacobi.^ It is true that all but 3 of these post-mortem 
examinations were made many years after the occurrence of the paralysis ; 
but in the 3 cases which were reported by Roger and Damaschino, only two, 
six, and thirteen months had elapsed. The following were the chief lesions 
observed in these cases as regards the spinal cord : 

Cases. 

1. Atrophy of motor-cells in anterior cornua 10 

2. Nerve-cells, normal 2 

3. Atrophy (variously recorded) of anterior columns, or cornua, or part 

of cord, or roots of anterior nerves . . 8 

4. Sclerosis 9 

5. Myelitis, recorded as diffused, central, or slight 7 

6. Central softening (the three most recent cases) 3 

7. Small clot in cord (Hammond's case) ... - 1 

8. Sciatic neuritis 1 

The most common lesions in these cases were those of inflammation of 
the anterior cornua of the spinal cord, or such as are known to result from this 
inflammation — to wit, atrophy of the nervous substance and sclerosis. 

With the data furnished by these post-mortem examinations and the clin- 
ical histories of cases we are better prepared to consider the theories regard- 
in 2; the etiology of this malady. The views of MM. Roger and Damaschino 
are entitled to much consideration, since the autopsies which they made were 
in cases of shorter duration, and therefore nearer the date of the commence- 

1 Jahrbuch fur Kinderh., 1873. 2 ^_ y. Med. Record, January 15, 1874. 

3 N. Y. Obst. Jour., for May, 1874. 



ETIOLOGY. 627 

ment of the paralysis, than those which have been reported by other observ- 
ers. Roger and Damaschino'^ published a series of papers on this malady, 
which they conclude with the following propositions: "1. The alteration 
peculiar to infantile paralysis is a lesion of the spinal marrow, which causes 
the atrophy of muscles and nerves. 2. The seat of this lesion is the ante- 
rior part of the gray substance of the medulla, where softened portions of 
spinal substance are seen. 3. This softening is of an inflammatory nature — 
in fact, a simple myelitis. -1. Infantile paralysis should therefore be called 
spinal paralysis of children, and be classed among the affections of the spinal 
marrow, as depending on myelitis." 

The views of Roger and Damaschino, expressed above, seem to harmonize 
more closely with, and to afford a more satisfactory explanation of, the symp- 
toms, history, and lesions thus far observed in ordinary or typical cases than 
does any other theory. Many neuropathists regard suddenly-occurring active 
congestion of the anterior cornua as the cause of infantile paralysis ; but 
there is that affinity between active congestion and inflammation that they 
may be regarded as having the same pathological effect in this instance, and 
therefore the two theories of a spinal congestion and spinal inflammation may 
be considered as one. It is not improbable that in some of the cases which 
more speedily recover there is simple congestion ; while in the more obstinate 
cases and those with inflammatory symptoms the congestion has passed into 
an inflammation or inflammation was present from the first. According to 
this theory, the atrophy so generally observed in the twelve cases in which 
autopsies were made must be considered a degenerative change resulting from 
the inflammation. That so accurate an observer and so excellent a micro- 
scopist as Robin could detect nothing abnormal in the case which he examined 
was probably due to the fact that the inflammation or congestion abated with- 
out producing any degenerative changes in the nervous substance. 

Professor Charcot regards atrophy of the motor-cells as the cause of the 
paralysis, but it is much more in consonance with the facts to consider the 
cellular atrophy a result than a cause. For how could atrophy, which always 
occurs gradually and by progressive increase, be the cause of a disease which 
begins abruptly and is most intense in the very commencement? Besides, 
atrophy does not occur without some antecedent disease to cause it. 

In a report to the International Congress at Amsterdam, Drs. Damaschino 
and Roger give the following summary of the result of their recent study of 
the pathology of infantile paralysis : ^ 

1. The anatomical lesions are situated in the motor regions of the spinal 
cord. 

2. They consist of a central myelitis, with a stadium of softening and 
atrophic destruction of the cells of the gray substance, together with sclero- 
sis of the lateral columns and considerable atrophy of the anterior roots and 
the nerves leading to the paralyzed muscles. 

3. Atrophy of the cells is not — as Charcot is of opinion — the whole pro- 
cess, as it is in progressive muscular atrophy. 

4. The opinion of Leyden, that there is a circumscribed and diffused mye- 
litis in children, is worthy of consideration. 

It remains for future examination to decide whether the myelitis begins 
as interstitial or parenchymatous in the connective tissue or the nerve-cells. 

Recent observations by Drummond (1885), Gowers (1888), and others have 
apparently established the theory of Roger and Damaschino — to wit, that 
the paralysis which we are considering results from acute inflammation of 
the gray matter of the spinal cord, and entirely or chiefly of the gray matter 
in the anterior cornua, that of the posterior cornua not being affected. 
1 Gaz. med. de Paris, 1871. '^ Le Frogres medical, No. 39, 1880. 



628 POLIOMYELITIS ACUTA ANTERIOR. 

All muscular fibres wliicli are in a state of disuse begin in a few weeks to 
atrophy and undergo fatty degeneration. The transverse striae in the primi- 
tive muscular fasciculus gradually disappear, and are replaced by granules 
of fat, and later still by small oil-globules. If we examine with the micro- 
scope the fibres from a muscle which has been a considerable time paralyzed, 
but which has still some electric contractility, we will find in places the striae 
remaining, but numerous opaque granules of a fatty nature within the sarco- 
lemma wherever the strige are absent, and in other places, where the degen- 
eration is most advanced, oil-globules occur, always small. If the paralysis 
be more profound, the striae have all disappeared. At a later stage, usually 
after some years in cases of complete and incurable paralysis, the fatty mat- 
ter may be to a considerable extent absorbed, and the fibrous network of the 
muscle which remains presents a tendinous appearance. There is a great 
difi'erence, however, in difi'erent cases as regards the rapidity with which 
these changes occur. Hammond states that he found the striae remaining in 
two cases after the lapse of more than four years of decided paralysis. The 
nerves of the paralyzed part also undergo atrophy. 

Diagnosis. — This is easy as soon as the attention of the physician is 
directed to the state of the limbs. In a large proportion of cases the mother 
or nurse first observes the paralysis and calls the attention of the physician 
to it. A knowledge and recollection of the facts in relation to this paral- 
ysis should lead the physician to examine the state of the limbs in all cases 
of fever in young children occurring without apparent cause. 

Prognosis. — It may be confidently predicted, if the child be seen early 
and correctly treated, that the paralysis will diminish, if it cannot be entirely 
cured. If the paralysis have continued a considerable time, and there be no 
electric contractility of the muscles, there is poor prospect of any improve- 
ment. The induced current will fail sometimes to cause muscular contrac- 
tion, when the direct current may produce it ; but if there be no response to 
the direct current, there is no therapeutic agent which can restore the use of 
the limb. 

In cases seen soon after the paralysis commences and before the stage of 
atrophy the prognosis is most favorable when there is still slight voluntary 
motion, and improvement commences early. In most instances, even when 
the paralysis has been mild and of comparatively short duration, the extrem- 
ity, although its motion be fully restored, is for a long time weaker than 
before the attack. 

Treatment. — A physician called at the commencement of the paralysis 
should endeavor to remove every cause which might increase the irritability 
of the nervous system. The bowels should be kept open and the diet be 
plain and unirritating. 

Local treatment is very useful at all periods of the paralysis. In the 
first days cold applications, as by an India-rubber bag containing ice, should 
be made over the spine. Stimulating embrocations over the spine and upon 
the paralyzed limb are appropriate after the cold has been discontinued, and 
benefit may also be derived from dry cups along the spine. Ergot, the bro- 
mide and iodide of potassium, which may be administered variously combined 
or singly, are the appropriate remedies for the first twelve or fourteen days. 
Administered every three or four hours in proper dose, they are the most 
effectual of all internal remedies for diminishing spinal congestion and pre- 
venting effusion and permanent structural change in the cord. Unfortu- 
nately, this first stage is in many instances far advanced before proper treat- 
ment is employed to subdue the myelitis, either from an incorrect diagnosis 
or because the physician is not summoned until structural changes have 
occurred, which constitute the second stage. 



TREATMENT. 629 

If the paralysis continue or if it do not progressive!}' diminish, we should 
not delay more than two weeks from the commencement of the disease before 
employing appropriate measures to restore the use of the limbs and arrest 
atrophy of the muscles. The expectant plan of treatment, which is proper 
in man}^ diseases of children, is unsuited to this. Muscular atrophy may 
commence in three weeks, and the farther it has advanced the more difficult 
and tedious will be the cure. Therefore, by the close of the second week, if 
the paralysis continue or be not rapidly disappearing, iron as a tonic with 
strychnia should be prescribed. There is probably no better formula for the 
exhibition of these agents than the following from Professor Hammond : 

R. Strych. sulphat., gr. j ; 

Ferri pyrophosphat., ^ss; 

Acidi phosphorici dilut., §ss ; 

Syr, zingib., o^j^s. Misce. 

One-third of a teaspoonful or one-ninetieth of a grain of strychnia is suffi- 
cient for a child of two years, administered three times daily. Hillier, Bar- 
well, and others have employed subcutaneous injections of strychnia, with, it 
is stated, a good result. While in the first and second weeks the child has 
been allowed to remain quiet, he should now be encouraged to use his limbs. 
Frequent muscular contraction must, if possible, be produced, and the volun- 
tar}' movements, when not totally lost, aid great]}' in promoting the nutri- 
tion of the muscles and restoring their function. Immersing the limb for 
half an hour in water at a temperature of 110° or 115°, rubbing the limb with 
a coarse towel, and kneading the muscles aid also in restoring nutrition and 
tone to them. 

But, fortunately, we have an invaluable agent in the electric fluid, which 
can be made to penetrate the muscles and cause their contraction when every 
other measure has failed. The induced current should be employed upon the 
limb every day or second day if it cause the muscles to act, but if the loss of 
power be of long standing or complete, so that the induced current is not 
sufficiently powerful, the direct current should be used instead. It is not 
regarded as important which way the current passes, provided that the mus- 
cles contract. 

In a large proportion of cases a cure cannot be effected until the lapse of 
several months, so that the patience of the physician and friends may be put 
to the test ; but if muscular atrophy can be prevented and the limb kept at 
nearly the normal temperature, this mode of treatment will ordinarily in the 
end be successful. The primary affection which caused the paralysis will, 
with some exceptions, be removed by the treatment indicated above, after 
which the state of the muscles and their nervous supply demand the whole 
attention. Observations show that by treatment perseveringly employed 
fatty degeneration of the muscular fibres can be not only arrested, but the fat 
which has already been deposited within the sarcolemma may be absorbed and 
the muscular striae restored. In those cases in which it has been necessary 
to employ the direct current the induced should be used whenever by the 
improvement of the case it is found sufficiently powerful. 



630 FACIAL PARALYSIS. 



CHAPTER Xyil. 

FACIAL PARALYSIS. 

Causes. — Facial paralysis in the new-born commonly occurs from pres- 
sure of the blade of the forceps upon the portio dura at a point external to 
the stylo-mastoid foramen. It may also occur in children of any age from 
exposure of the face to a cold wind. The pressure of a tumor upon some 
part of the portio dura, or even of the fist of the child placed under the face 
during sleep, may cause it. It may also result from disease of the temporal 
bone, producing pressure on the nerve, as caries, periostitis, suppuration, or 
hemorrhage into the aquseductus Fallopii, and also from intracranial disease 
affecting the pons A^arolii or the medulla oblongata. 

Symptoms.- — The portio dura, which is a nerve of motion, supplies the 
muscles of the face, and therefore its loss of function is at once manifest in 
distortion of the features. The eye of the affected side remains open in con- 
sequence of paralysis of the orbicularis palpebrarum, the upper lid being 
raised by the levator muscle, which is not paralyzed, since its nerve is derived 
from the third pair. From the inability to wink, the eye becomes irritated 
by dust and constant exposure, and in children old enough to have an abun- 
dant lachrymal secretion the tears are liable to flow over the cheek. On ac- 
count of the paralyzed and relaxed state of the facial muscles the mouth is 
drawn toward the healthy side, while the affected side presents a swollen 
appearance. Movement of the eyebrow of the anterior portion of the scalp 
on the paralyzed side is also impossible, since the occipito-frontalis and cor- 
rugator supercilii are supplied by the portio dura. If the cause of the dis- 
ease is located above the origin of the chorda tympani, the flow of saliva and 
sense of taste on the affected side are impaired. If the injury be posterior to 
the gangliform enlargement, those symptoms are superadded which are due 
to paralysis of the petrosal nerves. 

The accompanying Avoodcut represents a case which was under observa- 
tion in the New York Infant Asylum. Its age at admission was about five 
months, and its previous history was unknown. The paralysis was perma- 
nent. Death occurred some months later 
Fig. 39. from an intercurrent disease, and no cause 

of the paralysis could be discovered in a 
careful examination. 

Prognosis. — This depends on the cause. 
If the cause be peripheral, as from the pres- 
sure of the forceps or from cold, the prog- 
nosis is favorable. In case of deep-seated 
lesion, unless syphilitic, the prognosis is usu- 
ally unfavorable. A syphilitic lesion can 
often be removed by appropriate remedies 
and tiie paralysis be cured. 

Treatment. — In paralysis of the new- 
born from pressure of the forceps all that 
is required is occasional rubbing or gentle 
kneading over the affected muscles. In those 
who are older the nature of the cause, so far as ascertained, must deter- 
mine the treatment. If there be glandular swellings and discharge from the 




PSEUDO-HYPERTROPHIC PARALYSIS. 631 

ear from scrofula, cod-liver oil and the syrup of the iodide of iron are required 
internally, with appropriate external treatment of the glands and ear. If 
syphilis be the cause, mercurials and the iodide of potassium should be em- 
ployed. If the patient do not soon begin to improve, the treatment recom- 
mended for infantile paralysis, modified somewhat on account of the difference 
in location, is appropriate. Iron and strychnia may be administered inter- 
nally. The external treatment should consist of friction, kneading, hot appli- 
cations, and the electric current. The current should have only moderate 
intensity, for a high degree of it might injure vision. It should be applied 
every second day, with one pole over the mastoid foramen and the other moved 
slowly over the muscles. 



CHAPTEE XVIII. 

PSEUDO-HYPERTKOPHIC PARALYSIS. 

This is a rare disease. It was first described by Duchenne in 1861, and 
since the attention of the profession was directed to it cases have been 
observed on the Continent, in Great Britain, and in this country. Though 
our acqaintance with it is so recent, it has been fully and accurately 
described by various writers in our language. The Tramact ions of the Lon- 
don Pathological Societi/ for 1868 contain a translated paper relating to it, 
communicated by M. Duchenne, with photographic views and remarks by 
Lockhart Clarke, and also the histories of two cases occurring in London 
and exhibited to the Society by Adams and Hillier. In this country an 
elaborate paper has appeared on this form of paralysis from the pen of Dr. 
Webber^ of Boston, who succeeded in collecting the records of 41 cases; and 
more recently Dr. Poore,'^ physician to the New York Charity Hospital, col- 
lated the records of 85 cases, which furnish the material of his monograph. 

Weakness of the legs and a peculiar waddling gait are the first observ- 
able symptoms, and by them we are able to ascertain approximately the date 
of the commencement of the paralysis. In 27 of the cases collated by Dr. 
Poore the malady began so early in infancy that they were never able to 
walk like other children ; in 5 there is no record in regard to the time when 
the peculiar gait was first observed or whether they ever could walk ; 52, or 
about two-thirds of the cases, walked well at first, having no symptoms of 
the paralysis till after the age of two years. In 15 of these weakness of 
the legs and the peculiar gait were first observed between the ages of two 
and a half and five years ; in 23 between the ages of five and ten years ; in 
6 between the ages of ten and sixteen years ; and in 8 over the age of six- 
teen years. It is seen, therefore, that this malady is pre-eminently one of 
infancy and childhood. 

The gait, which is unsteady and waddling, has been compared to that 
of a duck. The child stands with the legs wide apart, and from the weak- 
ness of the legs and unsteadiness of the gait frequently stumbles and falls. 
In many cases this muscular weakness and difiiculty in walking occur 
before there is any perceptible enlargement of the muscles beyond the 
normal size. 

The hypertrophy occurs without tenderness, pain, or other nervous symp- 

^ Boston Bled, and Surg. Jour., Nov., 17, 1870. 
^ Neiv York Medical Journal, for June, 1875. 



632 



PSE UD 0-HYPER TR OPHIO PA RA L YSIS. 



Fig. 40. 



toms, and without fever or constitutional disturbance. Occasionally the 
patient complains of stiffness or aching in the limbs, especially after exer- 
cise, even before the enlargement is observed, and exceptionally there is 
pain, even acute, in the legs. The hypertrophy is ordinarily observed first 
in the calf of one leg, and then in the opposite calf. In a case related by 
Niemeyer the muscles of the gluteal region were first afi"ected. In nearl}^ 
all cases the gastrocnemii are hypertrophied. There were only 2 exceptions 
in the 85 cases collated by Dr. Poore, but almost any of the other muscles 
or groups of muscles may also be involved. The muscles which are most 
prominently affected and which produce the characteristic deformities are 
those of the extremities and posterior aspect of the trunk. Spinal curva- 
ture, which is attributed to the weakened state of the erector muscles of the 
spine, appears early and is seldom absent. The bending is such that a 
plumb-line, falling from the most posterior of the spinal processes, falls 
behind the plane of the sacrum ; and this is a means of distinguishing this 
disease from certain other spinal affections. The woodcut represents a case 

which came to the children's class at Bellevue 
in April, 1872. The boy was two years old, 
and the mother stated that the peculiar gait and 
the enlargements had only been observed from 
four to six weeks, and yet the curvature of the 
spine was quite marked. He did not return to 
the class, and his subsequent history is therefore 
unknown. 

Of the muscles in the upper extremities the 
deltoid and scapular are most frequently en- 
larged. Hypertrophy of the temporals has been 
observed in 3 cases, of the masseters in 2, of the 
tongue in 3, and of the heart in 4 (Poore). 

We shall see presently that atrophy occurs 
in the muscular element of the parts wdiich are 
affected, and that the hypertrophy is due to hy- 
perplasia of the connective tissue. Now, occa- 
sionally this hyperplasia does not occur or is tardy 
in occurring, while the atrophy has taken place. 
Therefore, certain muscles may have less than 
the normal volume, which, from contrast with 
those which are hypertrophied, increases the de- 
formed appearance. In ordinary cases the enlargement advances more rap- 
idly and continues greater in the gastrocnemii, which are, as we have 
stated, the muscles first affected, than in other muscles, and therefore 
the prominence and hardness of the calves of the legs are greater than else- 
where. In advanced cases walking is impossible, and the patient is obliged 
to remain in a reclining posture. Sometimes from the unequal muscular 
action the feet become extended and the toes flexed, so that the child in 
attempting to walk steps on the anterior part of the sole of the foot, as in 
talipes equinus. 

In the first stages of the disease the electric contractility of the muscles 
is nearly normal, but in advanced cases response to the galvanic current 
becomes more and more feeble according to the degree of atrophy of the 
muscular fibres. The skin retains its normal sensibility, with exceptional 
instances in which there is numbness either general or in places. Reddish 
or bluish mottling of the surface of the extremities is sometimes observed, 
which is attributed by some to obstructed venous circulation in the hyper- 
trophied muscles, and by others is supposed to be due to the peculiar neuro- 




ANATOMICAL CHARACTERS— CAUSES. 683 

pathic state. The bladder and rectum are not involved. The mental facul- 
ties are more or less blunted and feeble in certain cases, especially when the 
disease begins in early infancy, but in some patients they do not seem to be 
materially impaired. 

Anatomical Characters. — There have been so few post-mortem exami- 
nations of those who died having this disease that it is still uncertain whether 
there is any centric lesion. Cohnheim examined the spinal cord in one case, 
and could find nothing abnormal. Recently, Mr. Kesteven has examined the 
brain and spinal cord from a case, and found dilatation of the perivascular 
canals both in the brain and spinal cord, and also spots of granular degen- 
eration, chiefly in the white substance, " caused by loss of cerebral tissue 
replaced by morbid matter."^ As this child was imbecile, it is not improba- 
ble that these lesions were connected with the mental state and not the mus- 
cular disease. 

Professor Charcot^ reports a careful miscroscopic examination of the spi- 
nal cord and of the nerves in a case which had continued ten years. He 
could discover no deviation from the healthy state. More recently Dr. J. 
Lockhart Clarke^ examined a case and found the encephalon healthy, but in 
the spinal cord there was more or less disintegration of the gray substance in 
each lateral half, and in places dilatation of vessels and commencing sclerosis. 

It seems, therefore, that central lesions are not essential and are some- 
times absent. When they do occur it is probable that they are consecutive 
to the paralysis. 

The essential lesions in this malady are atrophy of muscular fibres and 
hyperplasia of the connective tissue which surrounds these fibres. The 
hyperplasia of the one element in the muscle is greater than the atrophy of 
the other, and hence the increase of volume above the normal size. The 
atrophy is probably a primary lesion, for muscular weakness ordinarily occurs 
for a considerable time before there is any evidence of the enlargement, and, 
as we have seen, certain muscles may undergo the atrophy without the hyper- 
plasia. Still, the mechanical effect of the newly-formed connective tissue 
doubtless increases the atrophy in those muscular fibres which this tissue 
surrounds, and the comparatively quiet state of muscles in consequence of 
paralysis not only tends to promote the atrophy and degeneration of these 
muscles, but also of contiguous healthy muscles. 

The muscles which are involved in this paralysis present a pale yellowish 
hue, resembling, says Niemeyer, the appearance of lipoma. Examining by 
the microscope, we find, in addition to a large increase in the fibrous tissue 
and atrophy, and in some places disappearance of the muscular element, more 
or less fatty matter, granular and globular, occupying the interstices. 3Ir. 
Kesteven describes as follows the appearance of the muscles in the case which 
he examined : '' The muscular substance is pale, almost white, and very greasy. 
The superabundance of fat is evident to the naked eye. The muscular fibres 
present the ordinary striation, but less distinctly than usual. The ultimate 
fibres are pale, and separated by a large increase of areolar and fibrous tissue." 

Causes. — Why there is this strange perversion of nutrition, so that there is 
an exaggerated development of the connective tissue of the muscles and atro- 
phy of the muscular fibres, is unknown. Boys are more liable to be affected 
than girls. Of the 85 cases embraced in the statistics of Dr. Poore, 73 were 
boys, and there was a similar excess of males in the cases collated by Dr. 
Webber. 

There is in a considerable proportion of cases the record of hereditary 
transmission, and in almost all the instances the predisposition is acquired 

^ Jour, of Med. Sci., Jan., 1871. ^ j^^chiv. de Physiol.. March, 1872. 

3 Medico-Chir. Trans., 1874. 



634 DISEASES OF THE SPINAL CORD AND ITS COVERINGS. 

from the mother's side. Thus in 37 of Dr. Poore's cases " 2 or more belonged 
to the same family." In some instances three and even four maternal rela- 
tives had this form of paralysis. In one case observed by Duchenne, and in 
a few others subsequently observed, this malady seemed to be congenital, for 
the limbs at birth were unusually large, and the patients when they came 
under observation were unable to walk. No relation has been observed 
between this paralysis and syphilis, scrofula, or other diathetic diseases. 

Prognosis. — This disease is in most instances progressive, terminating 
fatally after a variable period. It is in its nature chronic, rarely ending in 
less than five or six years. A considerable proportion live longer, some even 
attaining adult age. The paralysis may be stationary for a time, but after- 
ward continue to increase. Duchenne has reported one case of recovery. In 
two or three other instances patients appeared to improve somewhat under 
treatment, but the writers admit they may have become worse afterward. 
Death usually occurs, not directly from the paralysis, but from some inter- 
current disease, especially of the lungs. 

Treatment. — The treatment thus far employed has been chiefly local, 
consisting in the use of electricity and kneading or shampooing over the 
affected muscles. Both the primary and induced electric currents have 
been employed, but, unfortunately, without any appreciable benefit in most 
cases. Benedikt, who claims a better result from electrization than any other 
observer, applied the copper pole over the lower cervical ganglion, and the 
zinc pole along the side of the lumbar vertebrae by means of a broad metallic 
plate. 



CHAPTER XIX. 

DISEASES OF THE SPINAL CORD AND ITS COVERINGS. 

The diseases of the spinal cord and of the parts which cover and protect 
it are important, but they are less understood than are those of any other 
portion of the body. This is partly due to the fact that in many cases the 
spinal disease coexists with a similar pathological state of the brain or its 
meninges, the symptoms of which predominate and mask those which pertain 
to the spine ; partly to the fact that the chief symptoms of spinal disease are 
often located in organs or parts which are at a distance from the spine ; and, 
lastly, to the fact that it is difiicult, for obvious reasons, to determine the 
exact state of the spine at the bedside, while post-mortem inspection of the 
spine, which alone can give accurate pathological knowledge, is less frequently 
made than of any other organ. 

Certain spinal diseases occurring in childhood are the same as in adult 
life, presenting identical symptoms and lesions in the two periods, and there- 
fore they require no extended notice in this treatise. Others are common to 
childhood and maturity, but they present peculiarities in the former period 
which require to be pointed out, while others still are peculiar to childhood. 

The so-called spinal irritation or anaemic neuralgia is not infrequent in 
delicate and poorly-fed children. I have from time to time observed marked 
cases of it in the class in the Out-door Department of Bellevue, the patients 
usually being above the age of three or four years and exhibiting evidences 
of cachexia. Most of them have been spare and pallid, some affected with 
a nervous cough or palpitation, and some with neuralgic pains in the chest, 
abdomen, or elsewhere, which pressure at a certain point upon the spine 



' COXGESTION OF THE SPINAL COED AXD ITS MEMBRANE. 635 

intensified. These cases recover by better feeding, outdoor exercise, mild 
counter-irritation along the spine, and the use of tonics, especially of iron. 
Primary inflammation of the cord and its meninges is rare in children. 
Secondary inflammation of these parts is, on the other hand, more common 
in children than in adults. It is common in caries of the vertebras and in 
cerebro-spinal fever. The preponderance in functional activity of the spinal 
cord and the feeble controlling power of the brain render infancy and child- 
hood more liable to convulsions and reflex paralysis than any other period in 
life. Cases of true reflex paralysis occasionally occur in children, in regard 
to the etiology of which there can be no doubt. Prof. Sayre of this city has 
called attention to the fact that balanitis and preputial adhesions sometimes 
cause paraplegia, more or less pronounced, in young children, and which is 
relieved by dividing the adhesions and restoring the mucous surface of the 
glans and prepuce to its normal state. Such a case was brought to the chil- 
dren's class in the Out-door Department at Bellevue in April, 1875. The 
child could not walk or scarcely stand without support, but after the division 
of the adhesions and subsidence of the inflammation locomotion rapidly 
improved.^ In another instance a child could not walk properly, having a 
tottering gait and dragging one foot. The preputial and urethral orifices 
presented an irritated appearance. The prepuce was stretched and separated 
from the glans at a few sittings, the instrument used being an infant's catheter 
stiff"ened with a wire, so that it served as a probe. Large masses of smegma, 
nearly as far forward as the preputial orifice, were found underneath. These 
were removed, and the parts were smeared with sweet oil. The patient rap- 
idly recovered the full use of his limbs, and was soon entirely well. It is 
well known that masturbation sometimes causes a similar weakness of the 
lower extremities. Dr. West relates the case of a child " between two and 
three years old " who began to totter in his gait, and finally almost ceased 
walking. He was observed to practise masturbation. " This was put a stop 
to," and he soon recovered his health and his power of locomotion. - 



CHAPTER XX. 

CONGESTION OF THE SPINAL CORD AND ITS MEMBRANE. 

Congestion of the spinal cord and meninges occurs both as a primary 
and secondary malady, the latter being more frequent than the former. It 
may be active or passive. Active congestion, occurring independently of 
meningitis or myelitis, is in most instances transient and subordinate to some 
graver disease, in the course of which it arises. It is probably often over- 
looked. It is not fatal, and its symptoms are frequently masked by those 
which are referable to the brain or some other organ. It is believed to be 
common in the initial period of certain of the fevers of childhood. It is not 
improbable that the hypergesthesia observed upon the thoracic and abdominal 
surfaces and along the thighs in the commencement of remittent and certain 

^ Drs. Holgate and Bosley, formerly attending physicians in the children's class at 
Bellevue, made many examinations of the state of the prepuce in yonng children. 
They report that they found preputial adhesions almost daily, in most instances without 
symptoms, bat sometimes with dysuria, and occasionally with more or less impairment 
of the use of the legs. 

2 Dkeases of Children, page 146, 4th Amer. ed. 



636 CONGESTION OF THE SPINAL CORD AND ITS MEMBRANE. 

other febrile diseases has its origin in a congested state of the spine. To 
this congestion writers attribute the lumbar pain and occasional paraplepia in 
the initial stage of variola. Active spinal congestion may also result from 
the sudden impression of cold, and, as we have stated above, this is apparently 
the most frequent cause of poliomyelitis acuta anterior. 

Certain anatomical circumstances favor the occurrence of passive con- 
gestion of the spinal cord and meninges — to wit, the tortuousness of their 
veins and the absence of valves in these veins, the lack of muscular support 
of the vessels, and the inferior position of the spine in sickness as the patient 
lies quietly in bed. A common cause of passive congestion of these parts is 
some protracted and enfeebling disease which diminishes the contractile force 
of the heart (cardiac paresis), producing congestion of the spinal cord in the 
same manner as under similar circumstances hypostatic congestion of the 
lungs occurs. Severe convulsive diseases, as tetanus or eclampsia, when pro- 
tracted or occurring at short intervals commonly produce spinal congestion. 
In tetanus this congestion is extreme, so that extravasation of blood is liable 
to occur from the engorged vessels, especially those of the pia mater. 

Anatomical Characters. — It is often impossible, at post-mortem exami- 
nations, to determine how much of the congestion of the spine and its meninges 
is pathological and how much cadaveric, since, if the corpse be placed on its 
back at death, a very considerable engorgement of the spinal vessels occurs 
from gravitation of blood. If the body have been placed on the side or face, 
this cadaveric congestion is prevented. Since in active congestion the arterioles 
and capillaries are distended with arterial blood, the color is a brighter red 
than in passive congestion, in which venous blood predominates. Active con- 
gestion of the cord usually coexists with that of the meninges, but it ma}^ 
occur without it. In cases of considerable congestion the " puncta vascu- 
losa " appear upon the incised surface both of the white and gray substance. 
If the congestion be protracted or if it recur frequently, it may produce per- 
manent dilatation of the arterioles and capillaries in greater or less degree, 
and it may also lead to sclerosis of the cord. Passive congestion seldom, per- 
haps never, occurs in the cord without being equally and often to a greater 
extent present in the meninges. Continuing for a time, it gives rise to tran- 
sudation of serum into the interspaces over the cord, and even softening of 
the cord may occur to a limited extent from imbibition of serum. In either 
form of congestion extravasations of blood are frequent. 

Symptoms. — Spinal congestion is announced by pain in the region of the 
spine, usually in the lumbar or dorsal and lumbar portions, and irradiations 
of pain and tingling in the legs. In addition, more or less paralysis of the 
bladder and legs may result. The paraplegia may occur early or not till the 
lapse of several days. In active congestion the symptoms are rapidly devel- 
oped, and they attain their maximum intensity sooner than in the passive 
form. In passive congestion the development of symptoms is not only more 
gradual, but they are ordinarily less pronounced, and are attended by more 
fluctuation, than in the active form. The paralysis, if present, comes on 
slowly after several days, and is incomplete. Spinal congestion, especially 
of the passive form, is sometimes associated with cerebral congestion — as, for 
example, in tetanus and severe eclampsia — and the spinal symptoms therefore 
coexist with those which have a cerebral origin. The duration and the result 
of a hyperaemic state of the spinal cord and its meninges depend largely on 
the nature of the cause. If it be not relieved within a few days, there is 
strong probability that some other serious pathological state has supervened, 
as meningitis, myelitis, extravasation of blood, or serous transudation, with 
softening of the nervous substance. 

Treatment. — In the adult spinal congestion sometimes results from the 



VERTEBRAL CARIES. 637 

sudden cessation of the hemorrhoidal or catamenial flow, and the application 
of leeches or wet cups along the spine is indicated. But in the child the 
abstraction of blood is seldom required. In the acute stage of active spinal 
congestion, with elevation of temperature, cold applications along the spine 
are often beneficial, as by an India-rubber bag. 

In active hypersemia laxatives are useful, and rubefacient applications 
should be made along the spine, as by mustard or by friction with a stimu- 
lating liniment. In the inflammatory spinal congestion of cerebro-spinal fever 
I have employed with a very satisfactory result a liniment containing equal 
parts of camphorated oil and turpentine. In both active and passive hyper- 
eemia lateral decubitus should be prescribed rather than dorsal. The use of 
ergot in order to diminish the turgescence of the vessels of the spinal cord and 
meninges has been advocated by Brown-Sequard, and it is now one of the 
recognized remedies. Bromide of potassium is also a remedy of value, but 
it is more useful in some cases than in others. It is signally beneficial in 
those cases in which there is also cerebral congestion. When the congestion 
is increased or produced by clonic convulsions the bromide is one of the most 
reliable remedies which we possess for the removal of the cause. Thus, it 
should be employed in the treatment of the spinal and cerebral congestion in 
the commencement of variola, in which convulsions are so common, and in 
the convulsions of pertussis or pneumonia, which cause extreme passive con- 
gestion of the cerebro-spinal axis. Passive congestion of the spine, common 
in exhausting diseases and due to feebleness of the circulation, is best treated 
by stimulating and sustaining remedies and by the lateral decubitus. It is 
hypostatic, and may be associated with a similar congestion in the posterior 
part of the lungs. 



CHAPTER XXI. 

YERTEBEAL CAEIES. 

Vertebral caries, designated also Pott's disease, occurs chiefly in child- 
hood, but now and then adults are affected with it. It is an osteitis of the 
bodies of one or more vertebrae, ending in their ulceration and a lifelong 
deformity if not checked. 

Causes. — A reduced state of system, and especially the scrofulous diathe- 
sis, strongly predispose to caries. Hence this malady is more common in the 
city than in the country, where better hygienic conditions produce a more vig- 
orous constitution. Prolonged antihygienic conditions and protracted ill-health 
from whatever cause predispose to caries. In certain cases there is no appa- 
rent exciting cause, while in others there is the history of a fall upon or some 
injury of the spine. 

Vertebral caries may occur in the cervical, dorsal, or lumbar portions of 
the spinal column, but it is more common in the lower dorsal than elsewhere. 
With the development of the osteitis the body of the vertebra which is 
affected becomes hypersemic, and the .spongy tissue is soon infiltrated with 
blood and pus. The bone becomes swollen and softened, and therefore less 
resisting than in the healthy state, so that it yields under the weight of the 
shoulders and head, which it sustains. Therefore, after the osteitis has con- 
tinued a certain time there begins to be posterior convexity, or rather angu- 
larity, of the spine, for while the vertebral bodies soften and yield by the 



638 VERTEBRAL CARIES. 

weight above them, the arches retain their integrity and firmness and are 
unyielding. 

Much of the tediousness and suffering of this malady is due to the fact 
that the inflammation is so deep-seated and a healthy bony barrier is inter- 
posed between it and the surface, so that there is no ready escape of the pus. 
It permeates the spongy tissue, filling the cavities produced by the softening 
and absorption of the bone-substance. If the inflammation be of small 
extent, the amount of pus small, the constitution good, and if the disease 
be early recognized and properly treated, the child may recover without 
any fistulous opening by absorption of the pus, and with little remaining 
deformity. 

In the large proportion of cases, however, the history is diff"erent. The 
disease is not recognized till the stage of deformity, the caries, is so exten- 
sive and the pus so abundant that it escapes between the vertebrae, forming 
an abscess external to them which connects with the interior of the vertebras 
by a fistulous canal. This abscess, if in the cervical region, may press upon 
the pharynx or oesophagus or upon the air-passages, producing dangerous 
obstruction to respiration. This disease will be treated of hereafter. The pus 
may point and discharge externally near the seat of the caries, but in a large 
proportion of instances it takes a long and circuitous route to the surface or 
it opens internally. There are instances in which it discharges into the 
pleural or abdominal cavity or into one of the abdominal organs. If, as is 
sometimes the case, it establishes a connection with the intestine and escape 
in the stools, the result will probably be favorable. In other instances it 
descends into the pelvic cavity and finds an outlet by the inguinal ring or 
sciatic notch, or it enters the sheath of the iliacus or psoas muscle and points 
externally. 

When the disease ends favorably new bone is thrown out around the dis- 
eased vertebrae, preventing further bending and giving stability to the spine. 
If the abscess do not discharge, but remain subcutaneous, Billroth says : 
. . . . " While the bone disease recovers most frequently, a large part of the 
piis, whose cells disintegrate into fine molecules, is absorbed, while the inner 
walls of the abscess change to a cicatricial tissue which in the shape of a 
fibrous sac contains the puriform fluid. Such pus-sacs often remain in this 
stage for years." 

If the pus have escaped externally, the abscesses and fistulse contract and 
finally close, their site being occupied by condensed connective tissue. The 
portions of the diseased vertebrae which have retained their vitality are envel- 
oped and supported by the new bone, so that the part of the spine which was 
the seat of the disease, though ankylosed and curved, has greater firmness 
than in health. 

The history of unfavorable cases varies. The caries may extend ; pus, 
finding no vent, may accumulate in cavities and sinuses in which detached 
portions of bone float, or it may make its way in such directions that it pro- 
duces alarming complications and impairs or obstructs the functions of im- 
portant organs. 

Spinal meningitis in the vicinity of the caries, and due to extension of 
the inflammation, is common, and " the spinal medulla," says Billroth, "may 
be endangered by participation in the suppuration or by being so bent by the 
inclination of the vertebrae that its function is destroyed." Hence the paral- 
ysis of the lower extremities, bladder, and rectum which occurs in aggra- 
vated cases and which entails a fatal issue. In a certain proportion of cases 
the blood becomes more and more impoverished from the continuance of 
the inflammation and suppuration, and death occurs in a state of exhaus- 
tion. In such cases post-mortem examination often discloses waxy degen- 



SYMPTOMS— DIAGXOSIS. 639 

eration of important organs, as the spleen, liver, kidneys, and intestines, for it 
is well known that chronic suppurative inflammation of the bones is one of 
the two chief causes of the waxy disease, syphilis being the other. 

Sympto3IS. — Caries of the vertebrae is often preceded by symptoms or 
appearances which are due to the strumous cachexia. Strumous ailments 
have probably occurred in the patient or in members of the family, or with- 
out any clear history of struma the child has perhaps for some time been in 
failing health. In cases which I have observed one of the chief symptoms, 
and sometimes almost the onl}^ symptom in the commencement of the caries, 
has been neuralgic pain, usually not severe, intermittent, or more or less con- 
stant, at some point in the anterior aspect of the body, most frequently in the 
chest, epigastric or umbilical region. This pain has been present in a larger 
proportion of cases than pain in the spinal region at the seat of the caries, 
though Guersant dwells particularly upon the latter as a symptom of caries. 
Patients with this neuralgia are not infrequently treated for indigestion or 
worms, the true nature of the malady not being suspected and the spine not 
even being examined. This neuralgia seems to be due to compression of the 
spinal nerves by inflammatory exudation at the points where they emerge 
from the spinal canal. I can recall to mind a number of cases in which I 
have on different occasions been asked to prescribe for this neuralgia, which 
was shown by the sequel to be undoubtedly the result of vertebral caries, 
and yet with a careful examination of the spinal column I could discover no 
evidences of disease at any point. After a time, tenderness, pain, and inflam- 
matory induration, appreciable to the touch, may occur in or along the spine, 
but not usually till the malady is well advanced. Lassitude, fatigue after 
slight exertion, poor appetite, with slight fever, are common symptoms in the 
first stage of the caries. 

As the case advances, if the nature of the disease be not recognized and 
no artificial support of the trunk be provided, the child instinctively seeks 
some way of supporting the head and shoulders. He rests his head upon his 
hands or his elbows upon the table. Soon a gibbosity or angularity appears, 
affording clear and positive proof of the nature of the disease. Even now 
there is little or no tenderness when pressure is made directly on the spine. 
but it is observed more when pressure is made laterally upon it. If the 
inflammation extend so as to involve the meninges and the cord, pricking, 
tingling, numbness, or weakness of the legs may occur, w^hicli are symptoms 
of grave import, for it is probable that the case will end in paraplegia and 
death. A state of emaciation and general weakness, sometimes accompanied 
by diarrhoea and oedema of the limbs, precedes death. But a very consid- 
erable degree of curvature is not incompatible with a healthy and normal per- 
formance of all the functions, and the number who recover and live to an 
advanced age with deformity is large, as every one knows. 

Diagnosis. — This is often, from the nature of the disease, obscure and 
uncertain for a time. The long continuance of pain in the chest or abdomen, 
or perhaps in the thighs, without any cause which we can detect located at 
the seat of the pain, should excite suspicion of spinal disease. Such pain 
may be produced by spinal irritation, but in this malady pressure on the 
spine is badly tolerated, and when we touch a certain part the neuralgic pain 
is intensified. In caries, as we have seen, firm pressure upon the spine is 
tolerated, and it does not increase the neuralgia. At a later period in caries 
there may be spinal pain and tenderness, but there is now also spinal deform- 
ity, by which alone the diagnosis is clearly established ; stiffness observed in 
the movements of the spine, pain in the spine on sudden movement or jarring 
the body, impaired appetite and general health, and instinctive desire to sit 
or recline in such a way as to relieve the spine partially of the weight of the 



640 VERTEBRAL CARIES. 

head and shoulders, are symptoms which, if they coexist, afford very strong 
evidence of the presence of caries, although there be as yet no deformity. 

The spinal deformity of rachitis is distinguished from that of caries by 
the fact that it occurs slowly without pain or tenderness and is rounded 
instead of angular. Moreover, the rachitic diathesis precludes scrofulous 
ailments, and the scrofulous diathesis rachitic ailments, as the two diatheses 
do not coexist or but rarely ; so that if there be in the state of the patient 
or have been in his history evidences of scrofula, the presumption is that the 
bending of the spine occurs from caries. In a case of rachitic curvature we 
find also enlargements of the ankles and wrists, keel-shaped thorax, promi- 
nent abdomen, rachitic head, etc. 

Prognosis. — The course of this malady, even when the caries is slight 
and the symptoms mild, is tedious. In the most favorable cases the general 
health is but slightly impaired, the caries is confined to one vertebra, and is 
early diagnosticated and properly treated. On the other hand, if the general 
health be decidedly poor, the child anaemic and wasted, the curvature great, 
and an abscess have occurred, the case is very serious. Between these two 
extremes is every grade. The prognosis is more favorable in the child than 
in the adult. The few adults whom I have seen with it all died. It is less 
favorable in the cervical region than in the dorsal or lumbar. A mild case 
occurring in a good condition of health may become grave, and even fatal, 
by neglect and improper treatment. A majority of the patients, if the dis- 
ease be not too far advanced when recognized, recover if properly treated, 
but the deformity which results may prove serious in after-life. The incom- 
plete expansion of the lungs in the humpbacked greatly increases the dyspnoea 
and the danger in subsequent years if bronchitis or pneumonia occur, and if 
the caries have been at a low point in the spine and the patient a female, the 
deformity will probably present an obstacle to childbearing. 

Treatment. — The treatment must be constitutional and local, hygienic, 
medical, and mechanical. It is of the utmost importance to improve the 
general health, as it is in all chronic inflammations and scrofulous ailments. 
Pure air, sunlight, personal cleanliness, and plain but the most nutritious diet 
are required. Tonic and antistrumous remedies are indicated. To many 
patients I have prescribed, three times daily, cod-liver oil to which the syrup of 
the iodide of iron was added, giving two or three drops of the latter to a child 
of one year and one additional drop for each additional year. The judicious 
use of alcoholic stimulants will often be found useful if the appetite be poor 
and the general health seriously impaired, as will also the vegetable bitters. 

In all strumous inflammations of the bones which extend to or involve 
joints, and which are in their nature chronic, perfect quiet of the parts, so 
far as is consistent with the degree of exercise which is required in order 
to improve the appetite and general health, is indispensable for successful 
treatment of the case. The patient with this malady should be encouraged 
to lie much of the time in bed, for the double purpose of preventing move- 
ments of the inflamed vertebrse and relieving them of the weight of the. 
shoulders and head. But confinement in bed is badly tolerated, and exercise 
is necessary for a healthy functional activity of the organs ; therefore 
mechanical support of the spine is required. The apparatuses which have 
been invented for the purpose of supporting the spine and rendering it im- 
movable, and of sustaining the head if the caries be in the cervical region, or 
the head and shoulders if it be in the dorsal or lumbar region, are ingenious 
and effectual. Some of them are rather cumbersome, but others are sufficient- 
ly light for the youngest child who can walk. The apparatus should be worn for 
months, care being taken to prevent excoriation or undue pressure upon any 
point. It may be removed at night and reapplied on rising in the morning. 



SEOTIOT^ II. 
DISEx\SES OF THE EESPIEATORY SYSTEM. 



CHAPTER I. 
COEYZA. 

The term " coryza " is applied to inflammation of the Schneiderian mem- 
brane. It is acute or chronic. The acute form is primary or secondary. 
Acute primary coryza is common in infancy and childhood. Its usual cause 
is exposui'e to currents of air, to cold, and especially to sudden changes of 
temperature from warm to cold. The cause is the same as that in the ordi- 
nary forms of bronchitis. The two diseases frequently indeed coexist, occur- 
ring from the same exposure. The inflammation in such cases commences 
upon the Schneiderian membrane immediately upon the operation of the 
cause, and soon after extends to the bronchial tubes. Acute coryza may 
also be produced by the inhalation of irritating vapors, hot air, or dust, 
and also by the presence of a foreign body, as a button or bean, in the 
nostril. 

Secondary coryza is commonly due to a specific cause. The diseases in 
connection with which it occurs are whooping cough, measles, scarlet fever, 
diphtheria, and constitutional syphilis. In the infant coryza is one of the 
first manifestations of inherited syphilitic taint. 

Acute primary coryza ordinarily abates in from one to two weeks. The 
secondary form gradually declines, in most cases, when the primary affection 
on which it depends is cured. Syphilitic coryza is more protracted than the 
primary form or than that accompanying the eruptive fevers. Some children 
are so liable to coryza that it occurs whenever they take cold. Occasionally 
it is so frequently renewed in the winter months that it resembles the chronic 
form of the disease. 

Chronic coryza is commonly dependent on a dyscrasia, usually the syphi- 
litic or strumous. The dyscrasia is indicated by pallor, flabbiness of the flesh, 
and liability to glandular swellings. Certain cases take their origin in the 
nasal catarrh of the exanthematic fevers, the local aff"ection continuing after 
the constitutional disease has declined. Chronic coryza sometimes occurs in 
children who appear otherwise in good health. It is probable that in such 
cases there is a dyscrasia of which the coryza happens to be the sole mani- 
festation. 

Anatomical Characters. — The alterations which the nasal mucous 

membrane undergoes when inflamed vary considerably in different cases. In 

the simplest and most common form of coryza this membrane is sometimes 

in patches, sometimes generally reddened, thickened, and softened. Its papillae 

41 641 



642 COBYZA. 

are prominent, producing an inequality of the surface. Ulcerations are not 
common in simple acute coryza, but they sometimes occur in the chronic 
form . 

In diphtheria, and sometimes in scarlet fever and variola of severe type, 
the coryza is pseudo-membranous, and when it presents this form it is com- 
monly but not always associated with pseudo-m-embranous angina or laryn- 
gitis. A case of pseudo-membranous coryza occurring in measles is related 
by M. Guibert. The patient was a rachitic boy three and a half years old. 
The pseudo-membrane in grave cases may cover almost the entire surface of 
the nostrils, but ordinarily it occurs in patches. 

Symptoms. — The constitutional symptoms are mild or severe, according 
to the gravity of the inflammation. If the coryza be acute and pretty gen- 
eral, there is febrile movement, with thirst and loss of appetite. Frontal 
headache is common, from the proximity of the inflammation to the head or 
its extension to the frontal sinuses. Sneezing is the first symptom in many 
cases of acute coryza. As the inflamed membrane swells more or less obstruc- 
tion occurs to respiration. The breathing is noisy, especially during sleep, 
and in severe cases the patient is compelled to breathe mostly through the 
mouth. If there be much obstruction to respiration the suffering of the 
patient is considerable, from the sensation of fulness in the nostrils, the head- 
ache, and the muscular eflbrt required in each respiratory act. 

In the commencement of coryza the patient experiences a sensation of 
dryness in the nostrils, which is soon succeeded by a thin discharge of a serous 
appearance. In the course of a few hours the secretion becomes thicker. It 
is muco-purulent, and remains such till the disease begins to decline. Inspis- 
sated mucus and crusts are liable to collect within the nostrils and around 
their orifice in chronic coryza, and sometimes also in the acute disease if the 
discharge be not abundant. These crusts increase the difiiculty of breathing. 
Often the acridity of the discharge is such that the skin of the upper lip and 
around the nostrils is excoriated. 

Prognosis. — Uncomplicated catarrhal coryza rarely terminates fatally. 
It is only dangerous in young nursing infants, in whom it may prevent proper 
traction of the nipples. Coryza accompanying the eruptive fevers, although 
it may increase the suffering, does not materially increase the danger. Syph- 
ilitic coryza subsides when the system is sufficiently affected by antisyphilitic 
remedies. Chronic coryza is sometimes very obstinate. It may continue 
for months or years, giving rise lo a constant, but often not abundant, 
discharge. 

Treatment. — Common mild attacks of coryza require little treatment. 
The bowels should be kept open, the feet soaked in mustard-water, and the 
body should be warmly clothed. Inunction of the nostrils is a popular rem- 
edy, and it seems to give some relief. If coryza commence with symptoms 
which indicate a pretty severe attack, and there are evidences of extension 
of the disease toward the bronchial tubes, an emetic of syrup of ipecacuanha, 
given at an early period, moderates the severit}- of the inflammation and may 
prevent the occurrence of bronchitis. Afterward a simple diaphoretic mix- 
ture, as the following, should be given : 

R. Syrupi ipecacuanha, ^ij ; 

Spirit, sether. nitr., .^j ; 

Syrupi simplicis, ,f ij. Misce. 

One teaspoonful every three hours to a child of six months. 

In place of sweet spirits of nitre, acetate of potassium may be employed 
in the dose of one or two grains for infants ; and if there be considerable 



TREATMENT. 643 

fever half a grain or one grain, according to the age, of phenacetin or anti- 
pyrine may be given. 

A 3 to 5 per cent, solution of common salt in warm water injected into 
the nostrils with a small syringe aids materially in removing the muco-pus 
which obstructs the respiration and in establishing a healthier state of the 
inflamed surface. The officinal lime-water is also a most useful detergent of 
the nasal surface. The following formulae will be found useful in most cases 
of this form of coryza : 

R. Acidi borici, 3;] ; 

Sodii biborat., ,^ij ; 

Aquae, gviij. 

R. Sodii chloridi, •^] ; 

Sodii biborat., ,^ij ; 

Aquae, Oj. Misce. 

Half a teaspoonful, used warm, should be injected into each nostril several times daily, 
with the head thrown backward. 

The treatment proper for pseudo-membranous or diphtheritic coryza is 
detailed in our remarks on the therapeutics of diphtheria. Chronic coryza, 
since it depends upon a dyscrasia of which it is one of the local manifestations, 
requires remedies appropriate for the blood disease. Scrofula needs the 
syrup of the iodide of iron and cod-liver oil. The various ferruginous prepa- 
rations, as wine of iron, tincture of the chloride of iron, iron lozenges, and 
the vegetable tonics are also more or less useful. The diet should be nutri- 
tious and plain, and outdoor exercise and, if possible, country life should be 
enjoined. 

If the dyscrasia be syphilitic, similar invigorating measures are required, 
and mild mercurial inunctions to the nasal surface are especially useful. The 
following, which has been largely employed in the Out-door Department at 
Belle vue, is one of the best ointments for such cases, and its alterative effect 
renders it also useful for strumous coryza : 

R. Ung. hydrarg. nitratis, ^ij ; 

Ung. zinci oxid., ^ij. Misce. 

To be thoroughly applied to the Schneiderian membrane by a swab or cam- 
el's-hair pencil three or four times daily. Recently it has been modified by 
the substitution of Squibb's 5 per cent, oleate of mercury in place of the citrine 
ointment. If the coryza have a distinctly syphilitic origin, the application 
of a 2 or 3 per cent, oleate of mercury will fully meet the indication and be 
followed by improvement. 

Meigs and Pepper recommend the following ointment in chronic coryza, to 
be applied at night after the use of injections through the day : 

R . Unguenti hydrargyri nitratis, ^ss ; 

Extracti belladonna?, gr. x ; 

Axungiae, ^ss. Misce. 

Astringent injections into the nostrils are not often required in the treat- 
ment of the various forms of coryza ; but occasionally, if the discharge be 
protracted and abundant, weak astringent applications may be beneficial, as 
two or three grains of nitrate of silver or of alum or tannin to the ounce of 
water. It should be borne in mind that washes for the nasal surface should, 
as a rule, be employed tepid. 



644 LARYNGITIS. 



CHAPTER II. 

LAEYNGITIS. 
Catarrhal Laryngitis. 

Acute catarrhal lar37iig'itis occurs at all ages, but it is so common in 
infancy and childhood that it is proper to treat of it in a work relating to the 
diseases of these periods. Like other inflammatory affections of the air-pas- 
sages, it is most common in the cold months or when the weather is change- 
able. Its usual cause is, therefore, exposure to cold. Protracted and violent 
crying and the inhalation of acrid vapors are occasional causes. Catarrhal — 
or, as it is sometimes designated, simple — laryngitis also occurs in connection 
with certain constitutional diseases, among which may be mentioned measles, 
scarlatina, and variola. Laryngitis is also a common accompaniment of 
bronchitis and broncho-pneumonia, though its symptoms are liable to be 
obscured by those of the graver disease. It often likewise accompanies 
pharyngitis, due to extension of the inflammation. 

Sy3IPT0MS. — Catarrhal laryngitis produced by the impression of cold is 
commonly preceded by and accompanied by coryza. The initial symptom 
is chilliness, followed by sneezing and the discharge of thin mucus from the 
nostrils in consequence of irritation of the Schneiderian membrane. 

The commencement of laryngitis is indicated by hoarseness, which is 
apparent when the child cries or, if old enough, when it attempts to speak. 
There is often in severe cases complete loss of voice, so that speech above a 
whisper is impossible. I have noticed this most frequently in the laryngitis 
which accompanies measles. A cough occurs which is at first dry and husky, 
but becomes loose in the course of a few days. Expectoration is scanty, 
unless the inflammation have extended to the trachea and bronchial tubes. 

This disease is often accompanied by soreness of the throat, noticed in the 
act of coughing or when the larynx is pressed with the finger. In laryngeal 
catarrh, when uncomplicated, the respiration remains nearly natural and the 
pulse is but little accelerated. In mild cases the nature of the disease is 
often not apparent, as long as the child remains quiet, in consequence of the 
absence of symptoms, but the character of the voice when it cries or speaks, 
or of the cough, reveals at once the nature of the afl'ection. 

Acute laryngeal catarrh subsides in from one to two weeks. Occasion- 
ally it lasts three or four weeks before the symptoms entirely disappear. 
Death, which is rare, is due to some complication. 

Chronic laryngitis is much less frequent than the acute form. Its 
anatomical characters are similar to those in other chronic inflammations 
aff"ecting mucous surfaces — to wit, thickening and more or less infiltration 
of the mucous membrane, increased proliferation and exfoliation of the epi- 
thelial cells, and increased functional activity of the muciparous follicles. 

In the adult, chronic laryngitis is common as one of the lesions of the 
syphilitic or tubercular disease. In the child, syphilitic and tubercular laryn- 
gitis is more rare, but the latter sometimes occurs in connection with pulmo- 
nary or bronchial tuberculosis. Such patients are emaciated and have the 
ordinary symptoms of the tubercular disease. Chronic laryngitis also occurs 
in young children, usually infants, as one of the manifestations of the stru- 
mous diathesis. I have records of several such cases, mostly nursing infants. 



CATARRHAL LARYNGITIS. 645 

Some of these patients had mild bronchitis, but it was obviously subordinate 
to the laryngitis. Their respiration was noisy and harsh, continuing of this 
character several weeks and even months. The cough was also harsh and 
loud, conveying the idea of thickening and relaxation of the mucous mem- 
brane covering the vocal cords. Their respiration was not notably accelerated 
and the blood was apparently fully oxygenated, though the friends were often 
alarmed by the noisy breathing and cough. 

In this form of chronic laryngitis expectoration is scanty, the fever slight 
or absent, the appetite remains unimpaired, and the general condition of the 
child is good. From time to time exacerbations occur, and occasionally 
improvement is such as to encourage the hope of speedy cure ; but in the 
cases which I have seen there has not been complete intermission in the dis- 
ease till the final recovery. Those patients whom I have been able to follow 
through the disease have recovered in from three or four months to one year. 

Chronic laryngitis is to be distinguished from frequent attacks of acute 
laryngitis which are due to fresh exposures, and also from the laryngitis 
which is associated with bronchial phthisis. It is to be distinguished from 
protracted acute laryngitis, which sometimes does not entirely subside in less 
than a month or six weeks, by its longer duration, the greater thickening of 
the inflamed membrane, and more noisy respiration. Often chronic laryngitis 
results from the acute disease, the inflammation being perpetuated by the 
struma or dyscrasia of the patients. 

Anatomical Characters. — In acute catarrhal laryngitis the mucous 
membrane of the larynx presents the usual appearances of mucous surfaces 
when inflamed — namely, redness and thickening. It is also more or less soft- 
ened. Ulcerations rarel}', perhaps never, occur in primary acute laryngitis. 
When present in chronic laryngitis the ulcers are small and situated upon or 
near the vocal cords. Tubercular and syphilitic ulcers of the larynx are much 
more rare in children than in adults. The inflammation in simple acute laryn- 
gitis usually extends over the whole surface of the larynx and also to the 
upper part of the trachea. It may be pretty uniform or more intense in one 
place than another, and, like other mucous inflammations, it is accompanied 
by more or less proliferation and exfoliation of epithelial cells. In most cases 
of simple laryngitis, whether acute or chronic, the inflammation extends to the 
pharynx, producing redness and thickening, though generally moderate, of 
the mucous membrane which covers it. Examination of the fauces therefore 
aids in diagnosis. 

In the adult oedema glottidis occasionally results from laryngitis. In the 
child there is little danger that this will occur, in consequence of the anatom- 
ical character of the larynx, since in early life the larynx contains but little 
submucous connective tissue, and therefore less submucous infiltration or 
exudation occurs during the inflammation. The structural changes occurring 
in catarrhal laryngitis of infancy and childhood relate almost exclusively to 
the mucous membrane. 

Treatment. — Primary and uncomplicated catarrhal laryngitis requires 
little treatment. Most cases do well by the employment of suitable hygienic 
measures, without medicines. Benefit is. however, derived from the use of 
demulcent drinks and an occasional laxative. A mixture of paregoric and 
syrup of ipecacuanha or the mist, glycyr. comp. or a small Dover's powder 
will relieve the cough. For restlessness a warm foot-bath is also useful. 
Inhalation of the spray of glycerin and water from the atomizer, or of steam, 
plain or medicated, is also useful. Mildly stimulating embrocations, as by 
camphorated oil with or without a little turpentine, also aid. It should be 
rubbed several times daily over the throat, or a strip of flannel soaked with it 
may be applied around the neck. Chronic laryngitis dependent on syphilis 



646 LARYNGITIS. 

or tuberculosis requires the constitutional treatment which is appropriate for 
that disease. Measures not specific have little effect upon this form of inflam- 
mation. The chronic laryngitis which I have described as occurring chiefly 
in infancy, and which appears to be of a strumous character, is in most cases 
obstinate. The patient should be warmly clothed, and constant care should 
be taken that there be no exposure which would endanger taking cold, as this 
would produce an exacerbation of the disease and tend to counteract what had 
been gained by remedial measures. This form of chronic laryngitis is most 
satisfactorily treated by the application of tincture of iodine upon the neck 
directly over the larynx, and the internal use of cod-liver oil and the syrup 
of the iodide of iron. 

Spasmodic Laryngitis. 

This is a common disease. It is also called false croup, in contradistinc- 
tion to true or pseudo-membranous croup, and by some continental writers 
stridulous angina or stridulous laryngitis. It should not be confounded with 
spasm of the glottis, which is a form of internal convulsions and is not 
inflammatory. It occurs ordinarily between the ages of two and five years. 
It is commonly a sporadic affection, but Rilliet and Barthez state that "it is 
incontestable that it may prevail epidemically." They express this opinion, 
not from their own observations, but chiefly from those of Jurine, made in 
the commencement of the present century. 

Causes. — Children in some families are more liable to false croup than in 
others, so that an hereditary tendency to it must be admitted. The exciting 
cause in most cases is exposure to cold. False croup is not uncommon in the 
commencement of measles. Narrowness of the rima glottidis and an excita- 
ble state of the nervous system, both of which are common in early childhood, 
are predisposing causes. 

Symptoms. — Spasmodic laryngitis is ordinarily preceded for a day or two 
by a slight cough and fever, by symptoms of mild nasal catarrh, such as all 
children are liable to on taking cold. In exceptional cases these symptoms 
are absent and the disease begins abruptly. Singularly, it commences in 
most patients at night after the first sleep, between ten and twelve o'clock. 
The sleep is usually quiet and natural, but the child awakens with a loud, 
barking cough. There is great dyspnoea, and the respiration is harsh or 
whistling, on account of the narrowing of the chink of the glottis from the 
swelling and tension of the vocal cords. The face is flushed and expressive 
of suffering. The child cries, moves from one position to another, wishes to 
be held or carried, seeking in vain for relief. The skin is hot. pulse acceler- 
ated, the voice hoarse or even whispering. After a variable period, usually 
from half an hour to two or three — not more than half an hour with proper 
treatment — these symptoms abate. The patient is then somewhat exhausted 
and falls asleep. The face is less flushed or even pallid, the heat abates, and 
the pulse is less accelerated. The cough, though less frequent, remains for 
a time barking or sonorous, and respiration, though greatly relieved, is not at 
once entirely natural, but it gradually becomes so. In many cases the spas- 
modic respiration and cough do not recur, but sometimes the attack is repeated 
once or more, especially during the subsequent nights. The symptoms vary 
greatly in intensity in different patients. 

As the attack declines the disease, losing its spasmodic character, becomes 
a simple inflammation. In some patients the abatement of the cough and 
restoration of health are rapid, but oftener the inflammation extends not only 
into the trachea, but also into the larger bronchial tubes, and a tracheo-bron- 
chitis remains, which gradually declines. 



SPASMODIC LARYNGITIS. 647 

The termination is not always so favorable. Spasmodic laryngitis is, in 
exceptional instances, the precursor of other serious affections, which may 
prove fatal. It has been stated that measles often begins with spasmodic 
laryngitis. Bronchitis, becoming capillary, may occur in connection with it, 
as may also pneumonia, and by either of these severe inflammations the 
prognosis may be rendered doubtful. A few cases have been recorded in 
which it was believed that spasmodic laryngitis was of itself fatal. In some 
of these the dyspnoea was extreme and persistent and was the cause of death. 
In a case reported by Rogery, on the other hand, the respiration became easy 
before death and the pulse more and more frequent and feeble. Death 
apparently occurred from exhaustion. It is not improbable that had careful 
post-mortem examinations been made in those cases of spasmodic laryngitis 
which have ended fatally, other lesions would have been discovered besides 
those located in the larynx, perhaps tracheo-bronchitis, with an accumulation 
of mucus in the larynx, producing suffocation, or perhaps in some of the cases 
congestion of the brain or lungs and serous effusion. 

Anatomical Characters ; Pathology. — The opportunity does not 
often occur of determining the anatomical characters of spasmodic laryngitis. 
I have witnessed but one post-mortem examination. A little girl nine years 
old was taken on Frida}' night with cough and dyspnoea, indicating a pretty 
severe attack. The mother, acting through the advice of a friend, gave 
kerosene oil to her in considerable quantity. This was succeeded by obstinate 
vomiting and purging, which continued during Saturday and Sunday and 
terminated fatally on Monday. At the autopsy we found uniform and 
intense injection throughout the whole extent of the larynx and trachea and 
in the bronchial tubes, but there was no pseudo-membrane on the inflamed 
surface and but little mucus and pus. The solitary follicles of the intestines 
and Peyer's patches were tumefied, and the gastro-intestinal surface was 
injected in places. The cause of death was obviously the diarrhoea, appar- 
ently of an inflammatory character, and probably produced by the kerosene 
oil. The condition of the mucous membrane of the larynx was that which 
is ordinarily present in spasmodic laryngitis, though in some cases in which 
post-mortem examinations have been made the evidences of laryngeal inflam- 
mation were slight. Guersant relates a case in which the surface of the 
larynx seemed to be nearly in its normal state. Death in cases of slight 
laryngitis is due to causes which are independent of the larynx. In Guer- 
sant's case tuberculosis was present. 

There is, as has already been intimated, another and a more important ele- 
ment besides the inflammation in the pathology of spasmodic laryngitis — 
an element producing those phenomena which render it a disease distinct from 
simple laryngitis. I refer to spasm of the laryngeal muscles. This element 
pertains to the nervous S3^stem, so that spasmodic laryngitis is allied both to 
the neuroses and to inflammation. 

Diagnosis. — The disease for which spasmodic laryngitis is most fre- 
quently mistaken is pseudo-membranous croup. The friends, indeed, usually 
make this mistake in forming their opinion of the case before the physician 
arrives ; and there can be no doubt that many of the cases which have been 
published in medical journals as true croup were examples of this affection. 
The points of differential diagnosis are the following : True croup begins 
with symptoms which at first are slight, so as scarcely to arrest attention, 
but which gradually increase in intensity. The cough becomes more harsh 
and the respiration more difiicult by degrees. This increase in the gravity of 
the symptoms occurs by day as well as by night. On the other hand, false 
croup, though preceded by symptoms of nasal catarrh, commences abruptly. 
The symptoms have from the first their maximum intensity, and the time at 



648 LARYNGITIS. 

which it commences is at night. Again, the cough in spasmodic laryngitis 
possesses a lond, sonorous character, while in true croup it is harsh or rough 
from the presence of the membrane, and having, therefore, less fulness. 
The voice in spasmodic laryngitis may be hoarse, but it is not lost or is lost 
only for a short time. It afterward becomes natural or is slightly hoarse. 
On the other hand, in true croup the voice, froin being natural at first, is 
gradually extinguished. In fatal cases it soon becomes whispering, and con- 
tinues such till the close of life ; in those that recover the voice remains 
hoarse several days. These difierences are important, and if fully appre- 
ciated are in most instances sufficient to establish the diagnosis. Besides, in a 
large proportion of cases of true croup portions of the pseudo-membrane may 
be discovered on inspecting the fauces, and the faucial surface is deeply 
injected, while in spasmodic laryngitis there is, with rare exceptions, no 
false membrane upon the surface of the fauces and but a moderate amount 
of congestion. 

Laryngismus stridulus or internal convulsions must not be confounded 
with this disease. It is not inflammatory, but purely spasmodic, suddenly 
commencing and abating — identical, it is believed, in character with tonic 
convulsions of the external muscles, but affecting the internal muscles of 
respiration. This disease has already been fully described. 

Prognosis. — Little need be added, as regards prognosis, to what has 
already been stated. While a favorable opinion in reference to the result 
may ordinarily be expressed, the physician should not forget the fact that 
death may occur. Symptoms indicating an unfavorable termination are — 
great and continued dyspnoea, not diminished by the proper remedial mea- 
sures ; stridulous expiration as well as inspiration ; lividity of the prolabia 
and fingers ; pallor and coldness of surface ; pulse progressively more 
frequent and feeble. Convulsions and coma mav also occur near the close 
of life. 

Treatment. — The indications of treatment are twofold : first, to relieve 
the spasmodic action of the laryngeal muscles ; secondly, fo cure the laryn- 
gitis. To meet the first indication a warm bath of the temperature of about 
100° should be employed as soon as possible after the commencement of the 
attack. The patient should be kept in it ten or fifteen minutes, in order to 
obtain its full relaxing effect. In mild cases a warm foot-bath may be suf- 
ficient. A second means is the use of an emetic, which should be simulta- 
neous with the bath. To children under the age of three years syrup of 
ipecacuanha should be given, in doses of one teaspoonful repeated in twenty 
minutes, till vomiting occurs. Children over the age of three years, unless 
of feeble constitution, are best treated by the compound syrup of squills in 
teaspoonful doses, or a mixture, of this with syrup of ipecacuanha. It is not 
often necessary to give more than three or four doses, and sometimes one or 
two are sufficient to produce vomiting. 

In most cases by the use of the warm bath and the emetic the symptoms 
are rendered milder, and convalescence soon commences. 

Dr. R. R. Livingstone^ reports a case of laryngitis treated by Squibb's 
ether. It is stated that portions of pseudo-membrane from one-eighth to 
three-fourths of an inch in length were expectorated ; but the symptoms 
certainly indicated a spasmodic element as decided as in spasmodic croup, 
and the benefit from the ether was apparently due to the relaxation of 
the laryngeal muscles which it produced. The treatment of the patient, 
who was two years old, was commenced by the administration by the mouth 
of half a teaspoonful of the ether, and followed by its inhalation. " In pre- 
cisely eight minutes from the time the patient commenced the inhalation the 

^ American Journal of the Medical Sciences, April, 1867. 



SPASMODIC LARYNGITIS. 649 

abnormal muscular exertion ceased ; a general relaxation took place ; the 
pulse (which had numbered 150) fell to 100." Ether, judiciously employed, 
will probably prove to be a useful remedial agent in spasmodic forms of 
laryngitis, whether or not it have any effect on pseudo-membranous forma- 
tions. A large majority of cases, however, recover speedily without its em- 
ployment or by the other measures recommended. 

Attention should always be given to the state of the bowels in spasmodic 
laryngitis ; if they are not well open a purgative should be administered. 
For those that are robust and with considerable febrile movement the saline 
cathartics are ordinarily preferable, as Rochelle salts, or a purgative dose 
of calomel may be administered. The cathartic should not be prescribed 
till the nausea from the emetic has subsided. By its derivative effect it 
tends to diminish the laryngitis, and in severe cases it may obviate the 
need of depletion by leeches. 

Inhalation of the vapor of hot water and the application of a sinapism 
over the neck and upper part of the sternum, followed by an emollient poul- 
tice, are useful adjuvants to treatment. 

The most convenient and effectual way of employing vapor is, however, 
by the atomizer, and as the chief danger is that the inflammation may 
become pseudo-membranous, I am in the habit of using in the atomizer the 
officinal lime-water, its solvent action being increased by the addition of the 
sodium bicarbonate, two drachms to the pint. 

When the spasmodic element in the disease is relieved the case becomes 
one of simple laryngitis, and the general plan of treatment recommended for 
that malady is proper for this. Small doses of ipecacuanha or of one of the 
antimonial preparations, as the compound syrup of squills, not sufficient to 
cause nausea, should now be given at regular intervals. Antipyrine or phen- 
acetin, given every third hour in doses of half a grain, one grain, or one and 
a half grains, is a useful remedy if the temperature reach 103°. Its effect 
should be watched, and it should be discontinued when its sedative influence 
on the circulation begins to be apparent. 

If, however, the disease do not speedily terminate by recovery, or more 
rarely by death, there is nearly always tracheo-bronchitis or a more serious 
affection coexisting with the laryngitis or following it, so that depressing 
measures should not be long continued. Expectorants of a stimulating 
character, as carbonate of ammonium, are required in the course of a few 
days, and in young and feeble children they should be given at an early 
period. 

The mode of treatment recommended above is appropriate for that large 
•class in whom the inflammatory element predominates. In a smaller number 
of cases the nervous element predominates over the inflammatory, and the 
treatment should be in some respects different. Such children are usually 
pallid and of spare habit, having, indeed, the nervous temperament. They 
are liable to attacks of this disease, though generally of a mild form, on 
slight exposure to cold, and with a very moderate amount of inflammation. 
The treatment in these cases should be directed more to the nervous system. 
3Iy plan has been in the treatment of such patients, after perhaps the use of 
a, mild emetic, to give quinine, one grain three or four times daily, to a child 
from three to five years old, prescribing at the same time a simple expector- 
ant and a mildly irritating application to the throat. The symptoms in these 
cases are not severe and active measures are not required, though the peculiar 
cough continues longer than in the more inflammatory forms of the malady. 
The patient with spasmodic laryngitis should be kept in a warm room 
during the paroxysms, and should inhale an atmosphere loaded with 
moisture. 



650 MEMBRANOUS CROUP. 

Trousseau recommends a mode of treatment of spasmodic laryngitis which 
was first suggested by Graves of Dublin. It consists in the application 
underneath the chin, so as to cover the larynx, of a sponge soaked in water 
as hot as can be borne ; in ten or fifteen minutes it is repeated. This red- 
dens the skin, producing revulsion from the larynx. The hoarseness, 
dyspnoea, and cough diminish with this treatment, and some recover without 
other measures. 

In rare cases of spasmodic laryngitis the dyspnoea becomes so great, not- 
withstanding active treatment, that the life of the patient is in danger 
whether oedema glottidis or thickening and infiltration of the laryngeal 
mucous membrane be present. In these cases intubation with O'Dwyer's 
tubes will give prompt relief. Spasmodic contraction of the laryngeal mus- 
cles probably also occurs in these cases, increasing the dyspnoea. Recently, 
in the case of a child of about three years, the dyspnoea was so great in 
about three hours from the commencement that intubation was performed 
with immediate relief. 

Guersant and others speak of the importance of prophylactic management 
of children who are liable to this disease. Attention should be given to the 
dress, so that there may be sufficient protection from atmospheric changes, 
and there should be an equable temperature of the apartments in which they 
reside. Children of a decidedly nervous temperament, in whom the slightest 
laryngitis is liable to be spasmodic, require additional prophylactic measures. 
They are pallid and in a more or less cachectic state. Such children are 
benefited by chalybeate and vegetable tonics and by exercise in suitable 
weather in the open air. 



CHAPTER III. 

MEMBRANOUS CROUP (DIPHTHERITIC CROUP; TRUE CROUP). 

The term pseudo-membranous laryngitis or laryngo-tracheitis or true 
croup is applied to a common and fatal disease, the essential anatomical 
character of which is inflammation of the larynx or larynx and trachea, with 
the formation of a pseudo-membrane upon its surface. It occurs most fre- 
quently between the ages of two and twelve years, but infancy after the age 
of six months and early manhood are not exempt from it. For brevity I 
shall use the term croup in the following pages to indicate this form of 
inflammation, although recognizing another form of croup, the spasmodic or 
catarrhal, in which no pseudo-membrane occurs. 

Etiology. — Wherever diphtheria prevails as an endemic or epidemic it is 
well known that a large majority of the cases of membranous croup are local 
manifestations of this disease, and this inflammation is therefore in such 
localities commonly designated diphtheritic croup. Physicians have endeav- 
ored to discriminate between croup due to diphtheria and that from otiier 
causes ; but, whatever the cause, the anatomical characters, the clinical history, 
and the required treatment are so nearly identical that attempts to differen- 
tiate the disease when produced by other agencies than diphtheria from that 
due to diphtheria have proved futile and unsatisfactory in localities where 
diphtheria occurs, except in a few instances; as, for example, when croup 
has been manifestly caused by swallowing or inhaling some irritating agent. 

Inflammation of the laryngeal and tracheal surface, whatever its cause. 



ETIOLOGY. 



651 



whenever it reaches a certain grade of severity may be attended by the 
exudation of fibrin and the formation of a pseudo-membrane; but such a 
result more frequently occurs in the inflammation caused by diphtheria than 
in that produced by other agencies. In diphtheria a moderate laryngo- 
tracheitis is attended by the pseudo-membranous formation. 

The percentage of cases of diphtheria in which the larynx becomes 
implicated and croup occurs varies in different epidemics and in different 
seasons and localities. In epidemics of a mild type the cases appear to be 
fewer in which the larynx is involved than in epidemics of a severe form. 
In New York the percentage is large. From December 1, 1875, to July, 
1878, I preserved records of all the cases of diphtheria which came under 
my notice. The number was 104, and in 25 of these, or about 1 in 4, croup 
occurred, producing the usual obstructive symptoms and constituting the 
chief source of danger. During the two and a half years embraced in these 
statistics the disease was usually severe. Subsequently amelioration occurred 
in the type of diphtheria in this city, and the proportion of croup cases has 
not been so large. 

So commonly is membranous croup, when occurring in a locality where 
diphtheria is endemic or epidemic, a local manifestation of diphtheria that 
physicians in such localities come to regard every case of this disease of the 
larynx as produced by the diphtheritic poison. In New York physicians 
scarcely recognize any other form of membranous croup. It is well, there- 
fore, briefly to recall the evidences that croup in a certain proportion of cases 
results from other causes than diphtheria. The occurrence of croup in locali- 
ties where diphtheria is unknown of course indicates the operation of some 
other agency than the diphtheritic poison. Thus, in 1842, before diphtheria 
was established in this country. Dr. John Ware of Boston published his well- 
known paper on croup, and in 74 of the 75 cases embraced in his statistics 
the membranous exudation was present upon the faucial surface. The sta- 
tistics relating to the introduction of diphtheria into New York City and the 
recorded death-statistics of this city have been annually published, and each 
year more or fewer deaths from croup have been reported. The first death 
from diphtheria in this century within the city limits, certified by a physician, 
was that of a German woman at 638 Hudson street on February 15, 1852. 
Two other fatal cases occurred in 1857, and since then the deaths from croup 
and diphtheria have been as presented in the following table : 



Year. 
1858 
1859 
1860 
1861 
1862 
1863 
1864 
1865 
1866 



Croup. 


Diphtheria 


478 


5 


622 


53 


599 


422 


460 


453 


685 


594 


908 


981 


754 


781 


449 


534 


368 


435 



Year. 

1867 
1868 
1869 
1870 
1871 
1872 
1873 
1874 
1875 



Croup. 


Diphtheria 


338 


251 


342 


276 


483 


328 


421 


308 


466 


238 


675 


446 


732 


1151 


594 


1665 



'58 



2329 



Since 1875 weekly bulletins have been issued instead of the annual reports. 



Thus, in the first years after the introduction of diphtheria the deaths 
assigned to croup so greatly outnumbered those of diphtheria, as in 1858, 
when 5 died of diphtheria and 478 of croup, that it is evident that most of 
the cases of croup in those years were attributable to other causes than diph- 
theria. Since, as we have stated, any inflammation of the surface of the 
larynx and trachea, if sufficiently intense, may produce a pseudo-membrane, 
croup may occur as a primary disease and as a complication of various mal- 



652 MEMBRANOVS CROUP. 

adies. According to my observations in New York City, the chief causes of 
croup, arranged in the order of frequency, would be about as follows : Diph- 
theria, " taking cold," measles, pertussis, scarlatina, typhoid fever, irritating 
inhalations. I have elsewhere related cases of scarlet fever of severe type in 
which a thin film of pseudo-membrane was found upon the surface of the 
larynx and trachea, and there was no other lesion to indicate that diphtheria 
had supervened. The croup was, to all appearances, caused by the scar- 
latinous and not the diphtheritic poison. The following was a case in which 
croup was apparently idiopathic, and produced by that common cause of 
inflammations of mucous surfaces — to wit, exposure to sudden atmospheric 
changes. 

Case. — At midnight on October 22, 1884, I was summoned to a child aged 
twenty-five months who had been in the street till nearly nightfall, when the 
w^eather suddenly became much cooler and he was brought home. At 11.45 p. M. 
he awoke with a harsh voice and croupy cough, so as to alarm the family. I 
found the axillary temperature normal, but the fauces were injected, and the 
diagnosis was made of spasmodic or catarrhal croup. Emesis was produced by 
syrup of ipecacuanha ; the croup kettle and a mixture of potassium chlorate and 
ammonium chloride were ordered. 

On the following day he walked around the room and seemed better, but the 
inhalation of the vapor of lime from the croup kettle was continued. At 7 P. M. 
the symptoms became aggravated, the cough was frequent and hoarse, tempera- 
ture (axillary) 102^°, pulse 120, and respiration noisy. At my visit the post- 
clavicular, suprasternal, inframammary, and epigastric regions were depressed in 
each inspiration, though only to a moderate degree ; face flushed ; fauces injected, 
but without pseudo- membrane. The aspect was now more serious on account of 
the increasing dyspnoea. The pulse was strong and no pseudo-membrane was 
visible ; the temperature in the groin was scarcely 100°. Emesis had been pro- 
duced before my arrival, and in the matter vomited was a pseudo-membrane with 
ragged edges and about one-half an inch in length ; examined within an hour 
subsequently under the microscope, it was found to consist of fibrillse, evidently 
fibrinous, some of them wavy, and enclosing many pus-cells. Ten grains of cal- 
omel were placed on the tongue, and inhalations of the following were almost 
constantly employed by the steam-atomizer: 

R. Liq. potassae, .^ij ; 

Aq. calcis, S^ij- IVIisce. 

On the following day the respiration was easier, and within twenty hours the 
patient had so far convalesced as to be out of danger. There had been no case 
of diphtheria in the house, nor recently, so far as I could learn, in the immediate 
neighborhood. 

That this was a local disease, non-specific and quite distinct from the 
croup of diphtheria, cannot, I think, be doubted. 

In considering the etiology of croup, and recognizing diphtheria as by far 
its most common cause wherever the latter disease prevails, an interesting 
theory is suggested to which Heubner alludes, who affirms that inflamma- 
tions, even witii the characteristic membranous exudation, may be set up with- 
out the specific microbe of diphtheria, and then inoculation by the microbe 
occurs and "induces the general disease.'" The point alluded to is that 
inflammations arising from other causes than diphtheria now and then become 
intensified and are rendered more protracted and dangerous by the reception of 
the diphtheritic virus after the inflammations are established. In support of 
this opinion it is well known by all who have had much experience with diph- 
theria that those surfaces are prone to be attacked by the specific inflamma- 

^ "Die experimentelle Diphtheria," Leipzig, 1883, quoted in Ziegler's Pathol. AnaL, 
part ii. paragraph 444, 1884. 



ETIOLOGY. 653 

tion that are already irritated or inflamed when diphtheria is contracted. 
(This subject is alluded to in our remarks on Diphtheria.) 

Scarlatina is so often complicated by diphtheria that there seems to be a 
close affinity between the two diseases. It is a very common observation in 
New York City that scarlet fever continues two or three days in its usual 
form, when the symptoms become suddenly aggravated and the aspect of the 
disease more severe. On inspecting the fauces a pseudo-membrane is dis- 
covered covering this region, and it probably appears also upon the nasal 
surface. Although severe scarlatinous inflammation may cause a fibrinous 
exudation, yet that diphtheria has supervened upon scarlet fever in a consid- 
erable proportion of cases which have the above history cannot, I think, be 
doubted. In a few instances in my practice (four) the fact that scarlet fever 
was complicated by true diphtheria, and the scarlatinous inflammations, first 
in*order, were intensified by the presence and influence of the diphtheritic 
poison, was shown by the occurrence of diphtheria without scarlet fever in 
other members of the family. 

In accordance with the above law we may assume that a child who has 
laryngo-tracheitis, so common from taking cold and manifested by cough and 
hoarseness, is more prone to have diphtheritic croup than is one whose air- 
passages are in their normal state when diphtheria commences. A supposed 
error of diagnosis is often made by physicians, always to their discredit, who 
diagnosticate catarrhal laryngitis, but find after two or three days that their 
patients really have diphtheritic croup. A considerable number of such 
instances have come to my notice, always with the ill-will of families toward 
their physicians. Now, it seems to me that in many of these cases the ph}^- 
sicians have been right in their first diagnosis, and diphtheritic croup super- 
vened on the catarrhal inflammation. 

Another point relating to the etiology of diphtheritic croup requires 
notice. Many physicians who have had ample opportunities to observe 
diphtheria believe that the common way in which diphtheritic croup begins 
is as follows : The faucial or nasal surface is first affected, becoming covered 
by the peculiar exudation, and during inspiration particles of the pseudo- 
membrane containing the specific principle, being detached, lodge in the 
larynx. At the point of inoculation the specific inflammation arises and 
extends. This may be the manner in which the croup of diphtheria begins 
in certain cases, but it certainly does not apply to a considerable number of 
patients. Thus both the faucial and nasal pseudo-membranes may be treated 
every second or third hour from the time of their formation with the best 
disinfectants which we possess, so as to destroy all the micrococci in them 
and render them an inert mass, and yet croup not infrequently occurs during 
the progress of the case. Again, in certain cases croup begins at the com- 
mencement of the diphtheritic attack. The laryngitis commences as early 
as the pharyngitis, and therefore does not result from it. Sometimes the 
inflammation of the air-passages is from the first the predominant lesion, the 
pharyngitis being subordinate or even trivial. Thus, a bo}^ of two years ten 
months whom I attended died of croup lasting about four days. He lived in 
the suburbs of the city, where the houses were scattered and where there 
had been no recent diphtheria. The attack began with hoarseness, which 
gradually increased to a fatal obstruction in the air-passages. Close and 
repeated inspection of the fauces revealed only redness and some swelling of 
the parts that were visible, and the symptoms indicated but slight coryza. 
The diphtheritic nature of the disease was rendered certain by the occur- 
rence of diphtheria in its usual form in the two nurses immediately after the 
death of the child. In this case croup began at the beginning of the sick- 
ness, and it is evident from the history of the lesions that the contagium was 



654 MEMBRANOUS CROUP. 

not transferred to the larynx from any of the other surfaces. In view of the 
number of such cases I see no propriety in assigning to diphtheritic croup a 
mode of origin different from that of other diphtheritic inflammations. But 
the possibility, and perhaps probability, in some instances of an auto-infec- 
tion we will not deny. 

Anatomical Characters. — It is important' to acquaint ourselves with 
the anatomical characters of croup, especially with the nature of the pseudo- 
membrane, that we may know what measures to employ in order to remove it 
and prevent, so far as possible, the laryngeal stenosis from w^iich so many 
perish. The surface of the larynx, trachea, and in severe cases that of the 
bronchial tubes, is hyperaemic and swollen, and the inflammatory action 
involves more or less the submucous connective tissue, causing infiltration 
or oedema. The relation of the exudation to the mucous surface varies 
according to the kind of epithelium present. Where the epithelium is of 
the flat or squamous variety the fibrinous exudation from the blood-vessels is 
poured out around the epithelial cells, which perish. If the inflammation 
extend more deeply, the underlying connective tissue is also embraced in the 
coagulation and perishes. Prof. Ziegler of Tubingen, who has made repeated 
microscopic examinations of the pseudo-membrane, says : " It sometimes hap- 
pens that the dead epithelial cells become saturated with the exuded liquid, 
and then pass into a peculiar condition of rigidity akin to coagulation. The 
seat of this change appears to the naked eye as a dull, raised, grayish patch 
surrounded by red and swollen mucous membrane. The exudation is rich in 
albumen, and the transformed cells take on the appearance of a kind of 
coarse meshwork almost or altogether devoid of nuclei." This is superficial 
inflammation, and Prof. Ziegler next describes deep or parenchymatous 
inflammation, as follows: "It is characterized by the coagulation not merely 
of the epithelium, but also of the underlying connective tissue. The affected 
patch is swollen and assumes a whitish or grayish tint, the discoloration 
extending through the epithelium to the connective-tissue structures. The 
epithelium in some cases is lost altogether, and then the diphtheritic patch 

consists of dead connective tissue only The dead tissue is separated 

from the living by a zone of cellular inflammation. Fibrinous filaments are 
seen here and thete through the mass. The lymphatics in the neighborhood 
contain coagula and leucocytes." 

Squamous epithelium covers the nostrils, buccal cavity, fauces, and 
larynx upon and above the superior vocal cord, with the exception of its 
anterior aspect. The pseudo-membrane, therefore, upon all these surfaces 
lined with this form of epithelium consists of the exudate from the blood 
which surrounds and permeates the epithelium or epithelium and subjacent 
connective tissue. These two distinct elements, that poured out from the 
blood-vessels, and the normal tissue of the mucous surface now dead, incor- 
porated in one mass, constitute the pseudo-membrane. Its intimate relation 
with the surrounding living tissue is such that we cannot detach it without 
lacerating the latter and causing hemorrhage. 

The anterior aspect of the larynx from the middle of the epiglottis down- 
ward, all that part of the larynx below the superior vocal cord, the entire 
trachea, and the bronchial tubes, are lined by columnar epithelium. When- 
ever this variety of epithelium is present the exudate from the blood does 
not become incorporated with the mucous membrane, but escapes to the sur- 
face and coagulates in a layer over it. It is, therefore, loosely adherent to 
the underlying tissues, being attached to it by some fibrinous threads, and when 
it is peeled off the hyperaemic and swollen mucous membrane is seen under- 
neath in its entirety, unless, as is commonly the case, a considerable part of 
its epithelium has been shed and been expectorated. The loose attachment 



SY3IPT03IS. ^55 

of the pseudo-membrane in the trachea and bronchial tubes is of the greatest 
significance in its relation to intubation and tracheotomy. 

In this connection it is proper to call attention again to the confusion 
which occurs in the use of the terms diphtheritic and croupous as employed 
by pathologists on the one hand and clinical observers or practitioners on the 
other. Pathologists, following Yirchow, designate the inflammation " diph- 
theritic " when the epithelium and underlying tissues remaining in situ are 
blended with the exudate and become a part of the pseudo-membrane, what- 
ever may be the cause of the inflammation ; and they designate the inflamma- 
tion " croupous," whatever its cause, when the exudate escapes to the sur- 
face of the mucous membrane, as in the trachea and bronchial tubes, and 
coagulates upon it. Therefore, in all cases of pseudo-membranous inflamma- 
tion of the air-passages, even that due to '' taking cold " or to inhalation of an 
irritating vapor, they term the laryngitis diphtheritic, since in the larynx the 
exudate is incorporated with the mucous membrane, while the pseudo-mem- 
branous tracheitis or bronchitis in the same patient is termed croupous, since 
the exudate lies upon the surface. Practitioners, on the other hand, apply 
the term diphtheritic to all inflammations which occur as local manifestations 
of the specific disease, diphtheria, and to only such inflammations, whatever 
may be their form, whether pseudo-membranous or catarrhal. 

The epithelial cells embraced in the pseudo-membrane undergo a histolog- 
ical change. We have stated Ziegler's remark that they are permeated by 
the exudate of the blood. Cornil and Ranvier say : " Wagner admits the 
fibrinous degeneration of the cells. .... We have verified the description 
given by Wagner, but we would conclude that the cells are filled with a 
material which approaches mucin rather than fibrin." In the first week the 
pseudo-membrane forms more rapidly, and is usually thicker and more ex- 
tended, producing dyspnoea more quickly than when it forms in the declining 
stage of the disease. If the membrane be detached by the forcible coughing 
of the patient, it is usually quickly reproduced, unless the diphtheria be in 
its advanced stage and abating. If the croup continue from four to six days, 
the pseudo-membrane begins to soften from commencing decomposition and 
to disintegrate. The minute fibres which attach it to the membrane give way, 
and in favorable cases by the effort of coughing or vomiting it is thrown off". 
Separation is aided by the muco-pus which collects underneath. 

Symptoms. — Whenever croup is one of the local manifestations of diph- 
theria, such general or constitutional symptoms are present as commonly per- 
tain to this blood disease, such as fever, anorexia, thirst, and progressive loss 
of flesh and strength. The temperature in the commencement in croup from 
this cause is usually higher than at an advanced period, unless some compli- 
cation occur, as pneumonia, which increases the heat of the system. The 
temperature is not, however, in the beginning ordinarily above 103° or 104°, 
and as the croup continues and the systemic blood-poisoning becomes more 
marked, the temperature usually falls, so that even in the gravest cases it is 
often at or below 100°. Most patients also have those inflammations which 
commonly attend diphtheria — /. e. pharyngitis and more or less coryza, but 
they are relatively unimportant in comparison with the croup, for, unlike the 
croup, they do not in themselves involve immediate danger to life. 

Croup commonly begins gradually and insidiously, revealed at first to the 
physician by hoarseness or huskiness of the voice and a hoarse or harsh cough. 
Both voice and cough are feeble, lacking the fulness and sonorousness present 
in spasmodic laryngitis. In grave cases approaching a fatal termination the 
voice becomes more and more indistinct, and finally is suppressed. The 
cough also, which in the beginning of the croup was strong and expulsive, 
becomes feeble and ineffectual, and less frequent as the fatal result draws near. 



656 MEMBRANOUS CROUP. 

The amount of sputum varies considerably in different cases. If the 
inflammation extend no farther downward than the trachea it is scanty, but 
if there be coexisting bronchitis it is more abundant^ consisting of muco-pus 
with occasional flakes of pseudo-membrane. By vomiting a larger quantity 
is expelled than by the cough. Occasionally masses of pseudo-membrane of 
considerable size are expectorated, even moulds of some part of the respira- 
tory passage, always with great temporary relief to the patient. A pseudo- 
membrane of considerable thickness and extent obstructs the expectoration 
of muco-pus, which, collecting in the lower part of the trachea and in the 
bronchial tubes, greatly increases the dyspnoea. The respiration is somewhat 
more frequent than in health, but it is not notably increased except when 
bronchitis or broncho-pneumonia is present. At an advanced stage, when 
stupor supervenes from non-oxygenation of the blood, the respiration may be 
slower than in health. 

Croup in its commencement and in the active period of diphtheria without 
treatment almost never remains stationary or abates. Little by little, or often 
quite rapidly, the laryngeal stenosis increases, and soon the patient begins to 
experience the want of air. He becomes restless, has an anxious expression 
of the face, seeks change of position, reaching out his arms to the nurse or 
mother to obtain relief. In some patients only a few hours elapse and in 
others a day or more of gradual increase in the obstruction, when it becomes 
evident that death must soon occur unless relief be aff"orded. In this stage 
the post-clavicular, infraclavicular, suprasternal, and inframammary regions 
are depressed during inspiration, and the larynx is drawn with each inspira- 
tory act toward the sternum. While there is constant sufl"ering, there are also 
occasionally most distressing attacks of dyspnoea, attended by an increase in 
the lividity of the features and extremities, which now have an habitual dusky 
pallor. Sometimes these attacks are perhaps due to the doubling of a de- 
tached end of the pseudo-membrane on itself, or perhaps to a movement of 
the muco-pus by which bronchial tubes are occluded. With the ear applied 
over the larynx or upper part of the sternum, a loud rhonchus is heard both 
on inspiration and expiration, produced by the passage of the air over the 
obstruction, and obscuring to a great extent the other sound. Moist bronchial 
rales are also common. 

Those who recover from membranous croup without intubation or trache- 
otomy and by the use of inhalations — and thus far they constitute only a 
small minority — usually improve gradually, the obstruction diminishing by 
the softening and detaching of portions of the pseudo-membrane, the cough 
becoming looser and the voice less hoarse. After the detachment of the 
pseudo-membrane several days elapse before the thickening and infiltration 
of the mucous membrane disappear and the epithelial cells are restored. 

Diagnosis. — Catarrhal laryngitis with an unusual amount of thickening 
and infiltration of the mucous membrane and of the underlying connective 
tissue, so as to produce stenosis and obstruct respiration, may be mistaken for 
pseudo-membranous laryngitis. In the New York Foundling Asylum two 
children have at different times died with the symptoms of membranous 
laryngitis, and the obstruction was found to be due entirely to the thicken- 
ing and infiltration of the mucous and submucous tissues of the larynx by 
newly-formed corpuscular elements. Of course, death from catarrhal laryn- 
gitis is rare, but that this disease may produce such an amount of laryngeal 
stenosis as to cause even fatal dyspnoea, like that from the presence of pseudo- 
membrane, these two cases show. In most instances the diagnosis of mem- 
branous laryngitis from catarrhal laryngitis is easy by the presence of patches 
of pseudo-membrane on the fauces or by the history of the case, which evi- 
dently points to diphtheria as the cause. In the case alluded to above a child 



PROGNOSIS. 6^57 

in my practice died with the symptoms of acute laryngeal stenosis, with- 
out any pseudo-membrane upon visible parts and with only a moderate phar- 
yngitis. This case, which might have passed as one of catarrhal laryngitis 
accompanied by an unusual amount of cellular and serous infiltration, as there 
was no known diphtheria in the vicinity, was really due to diphtheria, and 
was a local manifestation of that disease, for immediately after the death of 
the patient the two nurses had unequivocal symptoms of diphtheria. The 
difficulty in using the laryngoscope in young children is such when their 
fauces are swollen that it has not heretofore afforded much aid in the differ- 
ential diagnosis of the various forms of acute laryngeal stenosis in young 
children, at least when employed by the general practitioner. 

Prognosis. — The mortality from croup obviously depends to a great extent 
on the prevalence and the type of diphtheria. From what has been stated 
above, it follows that croup is more frequent and more fatal when a grave form 
of diphtheria is prevailing than in mild epidemics with less blood-poisoning. 
In New York City, during the fifteen years ending with 1878, the percentage 
of recoveries was very small, both under medicinal treatment and tracheot- 
omy. During this long period, surgeons, not saving more than 3 to 5 per 
cent, of their cases by tracheotomy, performed this operation reluctantly. 
But since 1878 the percentage of recoveries after tracheotomy has been much 
greater. The mortality from croup is greater the younger the patients; for 
the younger the child the less the diameter of the air-passages and the more 
quickly laryngeal stenosis results. The younger the child, also, the more 
difficult is the use of the proper remedies, and the less the time for their use 
before fatal dyspnoea occurs. We have already said that croup appearing in 
the declining stage of diphtheria is less severe and more easily controlled or 
cured than when it occurs in the commencement of this disease. Much 
depends also upon whether the physician is summoned at the beginning of 
croup and appropriate remedies are early and persistently employed. In 
many instances the friends do not take alarm and the physician is not sum- 
moned till the disease is well under headway and there is not the requisite 
time for the action of inhalations. Obviously, also, croup, beyond all other 
diseases, requires faithful and intelligent nurses, for without the co-operation 
of such nurses night and day in the care of the patient the most judicious 
measures are often inefficient. 

Exact statistics are lacking to show what proportion of cases of croup 
recover by strictly medicinal treatment. If we regard as incipient croup 
those cases in which the voice becomes hoarse or harsh, but no dyspnoea 
occurs, and the lungs are fully and normally inflated, a considerable number 
— I think more than 50 per cent, in my practice — recover. There may be 
in these cases a catarrhal laryngitis, or there may be a thin film of pseudo- 
membrane upon the laryngeal surface, not sufficient to embarrass respiration. 
Slight laryngitis, therefore, occurring in the course of diphtheria, unaccom- 
panied by any increase in temperature or change in the freedom or rhythm of 
respiration, and whose only sj^mptom is a huskiness of voice, if treated early 
and properly by inhalations passes off in a few days in a large proportion of 
cases. It possesses little importance, except that it might be the initial stage 
of croup if neglected. It is obviously improper to consider this trivial form 
of laryngitis as membranous croup, although by neglect it might become such. 
In the statistics of croup those cases only should be included in which the 
symptoms are so pronounced that it is evident that more or less laryngeal ste- 
nosis is present, although there may as yet be no marked dyspnoea. 

In determining the percentage of recoveries in croup it is proper to arrange 
cases in two groups : 1st. cases which have received only medicinal treatment ; 
2d, cases in which intubation or tracheotomy has been performed. Having 

42 



658 MEMBRANOVS CROUP. 

been in almost continuous practice since diphtheria began in New York, in a 
section of the city where this disease has always been prevalent, and having 
witnessed all kinds of treatment — that by emetics, by depletion, by stimula- 
tion, by inhalation and insufflation — it is my opinion that not more than one 
in eight has recovered by medicinal treatment in this long period, of cases of 
croup which began in the first week of diphtheria, and in which the symp- 
toms were so pronounced as to indicate more or less laryngeal stenosis. The 
exudation in the first week of diphtheria, or in its active period, occurs so 
rapidly and in such large quantity that no one of the medicinal agents or 
modes of treatment which physicians commonly prescribe is sufficiently 
prompt in its action to prevent the formation of the pseudo-membrane to an 
extent that soon endangers life. I allude to what has hitherto been the result. 

Perhaps we may yet discover a mode of treatment that more effectually 
controls the formation of pseudo-membranes. 

Croup occurring in the second or third week of diphtheria, since it is 
attended by less abundant and less rapid exudation than when it occurs 
during the acute stage, can be more successfully treated under the persever- 
ing use of solvent inhalations, and, according to my observations, a larger 
proportion of such cases than 1 in 8 — perhaps 1 in 4 — recovers by the early 
and continuous or almost continuous use of inhalations. 

Still the mortality is so large and the suffering so great in croup, at what- 
ever stage of diphtheria it occurs, that we cannot rely on the slow action of 
medicines or inhalations, and surgical treatment is in most instances required 
to diminish the suffering and afford the best chances for saving life. Intuba- 
tion of the larynx by O'Dwyer's tubes is rapidly coming into use as a prompt 
and efficient method of relieving laryngeal stenosis. The percentage of 
recoveries after intubation will be considered hereafter, but enough is known 
to render it certain that this simple and painless operation will soon be per- 
formed as a substitute for tracheotomy in every part of the world where there 
is a medical profession worthy of the name. The following statistics show 
the result of tracheotomy when skilfully performed : 



Recov- 


Deaths. 


Per cent, of 


eries. 




recoveries. 


39 


127 




16 




24 


103 




31.2 


147 




29 
33 
25 

27 
32 



Jacobi, Krackowizer, and Voss [Amer. Jour, of Obstet., 

Mav, 1868) . 166 

J. H.'Kiplev, N. Y. Med. Rec, 1880 56 

Parisian Children's Hospital, 1851-75 (Tenne) . . . 4663 

Bethanien in Berlin, 1861-72 (Bartels) 330 

Berliner Chirurg. Klinik, 1870-76 (Kronlein) ... 504 

St. Annenspital, Wien (Monti) 210 

Table of Monti from various sources 2608 

Hofmohl's statistics 3760 

Kiister's statistics 1556 

C. Hospital, Trousseau, Paris, during 1883 (per Dr. 

L'Enfance) ^ 359 115 244 32 

Clinic of the Zurich Kantonspitals, under Eose and 

F. Kronlein, 1868, March, 1882 (11 under two 

years, 1 of eight months) . . 238 

Deutsche Zeihchrifi far Chirurg., 1882, Bd. xvii. (H. 

Lindner) 101 

Statistik der Tracheotomie per Croup, Deutsche 

Chirurger Lieferung, 37 Stuttgard, 1880, by Kiihn . 277 

Hopital des Enfants Malad., Paris, 1850-57 .... 389 

Hopital des Enfants Malad., Paris, 1860-67 .... 813 

Trousseau, according to Kiihn 466 

Guersant (Sedillot), Med. Oper., ii., page 480 .... 171 

Barthez, Hospital St. Eugenie, 1855-68 ...... 573 

Cases in the Parisian Hospitals and in the Provinces, 

Fascher et Bricheteau 1011 

Eoser (Lissard) CC, 1854-61 42 



92 


39 




37f 


125 152 . 


86 


22 


208 




126 


25 


36 


21 


160 


28 




25 


19 


45.4 



PROGNOSIS. 659 



Operations. 



Eecov- 


Per cer.t. of 


enes. 


recoveries. 


21 


25 


15 


33 


46 


35.6 


119 


31.75 


1 




5 





UMe, Archiv f. klin. Chir., 1S69, 1820-69 81 

Max. ]\[uiler (Langenb. Arch.f. klin. Chir., vii ) . . . 45 

Bardenheuer (Coiner Biirgerhospitals, 1875-76) . . 129 
Krankenhause Betlianien, 1873, and following (H. 

Settegast) 375 

Billroth, Chirurg. liinik. Wien, 1871-76 18 

Reisz, Bronchotomiens Tndicat., 1858 17 

Wansher {Copenhagener Kommuni Hospitals, Sept., 

1863-Dec., 1876) 400 170 42.5 

The result of tracheotomy in infants is mucli less favorable than in older 
children. Dr. Gustav Chagin^ has published the statistics of cases in infancy. 
These eases, 977, occurred since 1874, and of this number, 832, or 85 per 
cent., died. In the Copenhagener Kommuni Hospital, in which, as stated 
above, there was the remarkably good general result of 170 recoveries in 400 
tracheotomies, only 5 per cent, recovered of children under one year ; of 76 
operated on between the ages of one and two years, 22 recovered, or 29 per 
cent. ; while of 296 operated on between the ages of two and ten years, 146 
recovered, or 49.3 per cent. In the Krankenhause Bethanien the results of 
tracheotomy from the beginning of 1861 to the close of 1876, tabulated 
according to the age, were as follows (H. Settegast) : 

Years. Tracheotomies 

2 to 3 vears 93 

3 '• 4 ' " . . = 165 

4 '' 5 " 175 

5 " 6 " 107 

6 " 7 " 90 

7 " 8 " ^ 59 

8 " 9 " 24 

9 "10 " 15 

The statistics show that the older the patient upon whom tracheotomy is 
performed, other things being equal, the greater the percentage of recoveries. 
Prof. Abraham Jacobi has probably performed tracheotomy for croup in as 
many cases as any other physician or surgeon in this countr}- — not fewer, he 
thinks, than four hundred times. His opinion corresponds with the common 
belief that in recent years the percentage of recoveries after tracheotomy 
in New York City has been larger than in previous years, and the operation 
is performed more frequently by the attending physician than formerly. The 
result of tracheotomy during a long series of years, ending with 1878 or 
1879, was so unfavorable, on account of the type of the disease, that Dr. 
Jacobi thinks that in the aggregate of his cases of tracheotomy since 1858 
only about 12 per cent, recovered. 

Although at present in this city the percentage of recoveries after 
tracheotomy is larger than formerly, yet the statistics of some of the 
prominent physicians and surgeons show nearly as large a proportion of 
deaths as in former years, probably because the operation has been deferred 
till the patients were nearly moribund. Thus, one surgeon records only 4 
recoveries in 21 operations during three or four years, and a physician of 
large experience connected with one of the institutions where children are 
treated has been equally unsuccessful in his tracheotomies, but he has oper- 
ated only when the dyspnoea was extreme and death momentarily expected. 
Earlier operation might have given better results. 

The statistics of recent tracheotomies, which seem to me to indicate most 

^ Archiv fill' Kinderheilkunde, Bd. iv. 



Kecovered. 


Per cent. 


22 


23.65 


47 


28.45 


54 


30.85 


39 


35.45 


34 


37.77 


17 


38.86 


11 


45.83 


6 


40.00 



660 MEMBRANOUS CROUP. 

accurately the results of this operation when skilfully performed, and not at 
too late a stage in the type of diphtheria now prevailing in this city, I have 
obtained from Drs. J. H. Ripley and Fred. Lange. The operations embraced 
in their statistics were performed since January 1, 1879, and before intuba- 
tion came into general use, with the following result : 

Tracheotomies. Died. Recovered. Per cent, of recoveries. 

66 44 22 33^ 

These surgeons did not select cases for the operation, but operated on 
nearly every patient with croup to whom they were summoned, provided that 
death appeared inevitable without tracheotomy. They operated even if serious 
complications were present, as nephritis or pneumonia, or the blood were pro- 
foundly poisoned. 

Some physicians in this city make greater discrimination in cases, and do 
not operate if the condition of the patient be such that death will in all 
probability occur after tracheotomy. They do not, therefore, advise the 
operation if the patient have profound blood-poisoning or severe local disease 
elsewhere than in the air-passages. Such physicians by the early perform- 
ance of tracheotomy and by careful attention to the after-treatment, making 
frequent visits and supervising the details of the management, furnish more 
favorable statistics of the operation than those published above. Thus, Dr. 
A. R. Robinson, who carefully considers the indications and contraindications 
of tracheotomy, who operates early, does not insert the canula until all loose 
muco-pus and shreds of pseudo-membrane are expelled by the cough from 
the trachea and bronchial tubes, and who supervises by frequent visits the 
after-management, has saved, since 1880, 11 in 13 consecutive cases of 
undoubted membranous croup. It is seen from the above statistics that we can 
claim from tracheotomy, judiciously performed and at a sufficiently early 
stage, the cure of 1 in every 3 patients on the average. The statistics in 
Boston show that the results obtained in that city in hospital practice have 
been about the same as those in New York and in European cities. In an 
interesting paper on tracheotomy in croup, published in the Medical News, 
July 12, 1884, the writer says: " Tracheotomy for this disease has been per- 
formed 118 times at the Boston City Hospital during the past twenty years: 
39, or 1 in 3, were successful. That the cases were not selected is shown by 
the fact that 3 patients died during the operation from shock and exhaustion, 
not from hemorrhage ; 34 died within twenty-four hours ; and 56, or more 
than erne-half of the fatal cases, within forty-eight hours ; 4, if not 5, of the 

successful cases were practically moribund at the time of the operation 

The ages of these patients ranged from nine months to forty-one years. 
The youngest to recover was eleven months, the oldest sixteen years ; 4 
aged two years and 5 aged three years got well. Membrane was visible in 
the fauces or trachea in a large proportion of both the successful and unsuc- 
cessful cases. Its absence was noted in only 3 of each class. It need not 
be said that in every instance there was present severe, constant, and increas- 
ing dyspnoea, exhausting the strength and threatening suffocation." 

Treatment — Preventive. — In attending a case of diphtheria the phy- 
sician should notice at each visit whether the patient have any hoarseness or 
other signs indicating implication of the larynx, since if the danger be recog- 
nized at its inception it may perchance be averted. Ineffectual as inhalations 
may be for fully-declared croup, we have seen, in speaking of the prognosis, 
that experience fully justifies the belief that they are sufficient in a large 
proportion of cases to relieve that degree of laryngitis which is indicated by 
simple hoarseness, and which if it continue might eventuate in serious 



TREATMENT. 661 

obstructive disease. If the physician observe such symptoms, he should 
immediately recommend that the air in the apartment be kept moist by the 
croup kettle or pans of hot water over the fire, into each of which a lump 
of lime is placed. I frequently surround the bed with a tent made with a 
clothes-horse, over which blankets are thrown, and place the croup kettle 
underneath. Frequently stirring the water in the kettle adds to its efficiency. 
I prefer, however, in most instances, to employ the steam-atomizer either with 
or without the croup kettle. It should be so constructed that it throws a 
heavy spray of rather turbid lime-water, and should be almost continuously 
used as long as the premonitory symptoms of croup continue. It obviates 
the necessity of heating the apartment, which in hot weather is very uncom- 
fortable. 

It is proper, in this connection, to consider which is the most efficient and 
the best agent for inhalation in croup. Have we an agent that can be safely 
used, which will prevent, when inhaled, the formation of the pseudo-mem- 
brane, or which will dissolve it when it has already formed ? The agents 
which have been most employed for this purpose are lime-water, lactic acid, 
pepsin, and trypsin. 

In selecting the one that is safest and most efficient, the important fact 
should be borne in mind that anything which irritates, so as to increase the 
inflammation of the mucous surface, is injurious. Whatever intensifies the 
inflammation evidently augments the thickening and infiltration of the mucous 
membrane and increases the area as well as thickness of the pseudo-mem- 
brane. It is therefore harmful instead of beneficial. In my opinion, the 
teachings of Bretonneau and Trousseau did immense harm in the fact that 
they brought into use agents far too irritating to the sensitive mucous sur- 
face. Since the pressing danger in croup arises from the obstruction pro- 
duced by the pseudo-membrane and by the thickening and infiltration of the 
mucous membrane underneath, that agent is indicated, if it can be found, 
which loosens and dissolves the pseudo-membrane, and at the same time tends 
to diminish, or at least does not increase, the inflammation of the underlying 
tissues by its irritating action. Alkalies exert a solvent action on fibrin and 
mucin, and as the pseudo-membrane consists of the exudate from the blood 
largely fibrinous, and of epithelium and connective tissue which have under- 
gone degeneration into a substance resembling fibrin (Wagner), or perhaps 
mucin (Cornil and Ranvier), their employment seems to rest on a sound ther- 
apeutic basis. Lime-water slightly turbid, but not so turbid as to clog the 
point of the steam-atomizer, with its alkalinity increased by the addition of 
an unirritating alkali, should be employed almost continuously by inhalation. 
Dr. E. M. Moore ^ of Rochester recommends insufflation of sodium bicarbonate 
as an active solvent of the pseudo-membrane. It possesses this advantage — 
that it is but slightly irritating, so that it can be used in substance or with 
but little dilution. For this reason it should be preferred to lime-water, 
which is in more common use. 

Recently I have employed in the steam-atomizer the following formula, 
with good results • 

Sodii bicarbonat., ,^ij ; 

Aquse calcis, Oj. Misce. 

Trypsin may be advantageously used with this liquid, but trypsin in pow- 
der is very likely to clog the atomizer. The liquid trypsin, as prepared by 
Fairchild, should therefore be employed with the lime-water. Pepsin, as we 
have stated elsewhere, is incompatible with an alkali. 

By the persistent and timely use of such inhalations as soon as hoarse- 

^ Transactions of the N. Y. Merh'cfd Association, 1885. 



662 , MEMBRANOUS CROUP. 

ness appears croup can be often prevented. But we all know how fre- 
quently, notwithstanding our best endeavors, croup occurring in the first 
week of diphtheria grows hourly worse. In these acute and rapid cases 
inhalations of the best agents which physicians have hitherto used act too 
slowly to prevent the growth of the pseudo-membrane, and in a few hours it 
becomes painfully evident that something more must be done or the life of 
the child is lost. In those many cases' in which diphtheria is ushered in with 
croupous symptoms, and in which within a few hours laryngeal stenosis 
begins to occur, the experienced physician sees at a glance, often at his first 
visit, that inhalations, however faithfully employed, will be inadequate, and 
that sufi'ocation, the most painful of all modes of death, will be inevitable 
unless other and energetic measures are used. 

On the other hand, in the milder forms of croup, in which the exudation 
has but moderate thickness and forms slowly, inhalations are of the greatest 
service, and aided by internal remedies they not infrequently arrest the dis- 
ease and save life. The following was such a case : " M. J , a girl of 

two years and five months, took diphtheria on January 6, 1884. I first saw 
her on the 9th, when a considerable amount of pseudo-membrane covered the 
fauces. The temperature was but moderately elevated, and a slight discharge 
occurred from the nostrils. Under the usual treatment the pharyngitis 
abated, and she seemed to be convalescing until Januar}^ 14th, when her 
respiration began to be noisy and embarrassed. On inspecting the fauces a 
pseudo-membrane was seen upon the aperture of the glottis, apparently dip- 
ping down into it. The steam-atomizer was employed almost constantly, 
throwing a spray of lime-water with about 1 per cent, of liquor potassae. 
Each inspiration was accompanied by marked depression of the post-clavicu- 
lar, epigastric, and inframammary regions, and the respiration was noisy 
and embarrassed till the 17th, when it began to improve, and the patient was 
soon out of danger. It will be observed that the croup commenced in the 
second week or in the declining stage of diphtheria. Had it been earlier, 
when the inflammation was more active and the exudation more rapid, in all 
probability the patient would have perished unless saved by tracheotomy. 
The slowness of the exudative process afforded time for the action of solvent 
inhalations. 

Nearly at the same time that this case occurred a patient in my practice 
who had recovered from croup by tracheotomy was seized with dyspnoea a 
month after the operation, when the opening had healed, and a flapping sound 
could be distinctly heard, produced probably by a pseudo-membrane which 
was partially detached. This obstruction, which for a time apparently 
involved great danger from the dyspnoea which it caused, was removed by 
the third day under alkaline inhalations. In such cases, in which the inflam- 
mation is mild and the exudation at a standstill or slow, the benefit from 
inhalations is most apparent. I am confident that one good result from alka- 
line inhalations is not fully appreciated by the profession : I refer to the fact 
that the}^ render the muco-pus, which collects in large quantity in the bron- 
chial tubes, and is expectorated with difliculty on account of its viscidity and 
the obstacle above it, thinner and more easily expelled. 

Now that diphtheria has become so prevalent in this country, and so many 
children perish of the croup which it produces, it is to be hoped that some 
more efficient and at the same time unirritating substance may be discovered 
for inhalation than those at present in use. 

Since my attention has been called to the fact by Dr. A^an Syckel of New 
York that trypsin, one of the digestive ferments secreted by the pancreas, is 
a rapid solvent of fibrin, he having observed its action in the laboratory of 
Prof. Kiihne of Heidelberg, I have employed this agent in the usual form of 



TREATMENT. 663 

diphtheria in several instances with such result as to encourage the hope that 
the solvent which we have so long needed has been found. I have never 
seen pseudo-membranes disappear from the fauces more rapidly than in cases 
in which the following mixture w^as applied every half hour with a large 
camel's-hair pencil, whether the good effect was due to the trypsin contained 
in the extract or to the alkali, or to the combination of the two : 

Extracti }mncreatis (Fairchild's), 5J ; 

Sodii bicarbonat., ^iij. Misce. 

Add one teaspoonful of this to six teasi^oonfuls of water. 

Thus recently, in a child of about five years a thick pseudo-membrane 
over each tonsil had disappeared by the third day, without apparently any 
irritating effect from the application. Mr. Fairchild has recently prepared 
trypsin in a liquid form in order that its efficacy can be more readily and 
conveniently tested as a solvent for the membranes in croup ; and different 
observers state that this liquid employed in spray has in certain cases exerted 
a marked solvent action on pseudo-membranes. Additional clinical observa- 
tions will determine the value of trypsin as a solvent. That it requires an 
alkaline medium for its activity renders it compatible with alkaline inhala- 
tions, as we have stated above. 

Internal Trf^atment. — Calomel. — This was long regarded as the most 
important internal remedy for membranous croup, as well as for diphtheritic 
exudations elsewhere than in the larynx. In the belief that it had a tend- 
ency to prevent the formation of pseudo-membranes, and aided in detaching 
and removing those already formed, it was in common use until about 
twenty-five years ago. It was sometimes prescribed for croup in large doses, 
but more frequently in doses of one-half, one, or one and a half grains, 
repeatedly every second or third hour, and often in combination with an 
opiate, as Dover's powder. However useful a remedy it may be when judi- 
ciously employed in croup as w^ell as in certain other diseases, it fell into dis- 
use on account of its ill-advised use in diseases which did not require it. often 
to the extent of producing unpleasant and even dangerous symptoms. When 
diphtheria was established in this country calomel was in a few years dis- 
carded by most physicians as a remedy for croup, on account of the growing 
belief that nearly all cases of this disease were local manifestations of diph- 
theria and required less depressing and more sustaining measures than mer- 
cury. Moreover, it was easy to point out cases in the writings of such mas- 
ters of the profession as Bretonneau and Trousseau in which calomel was 
improperly employed, doing harm by causing not only severe salivation, but 
also gangrene. Nevertheless, cases occurred in those days which seemed 
to show that this agent, properly employed, is a potent and useful remedy 
for croup. One in the Astor House of New York attracted attention. A 
child of about two years stopping at this hotel had pseudo-membranous 
laryngitis, with constantly increasing dyspnoea. Prominent physicians sum- 
moned to him expressed the opinion that he could not live, when, through 
the advice of a physician from an inland city who was temporarily sojourn- 
ing in the hotel, twenty grains of calomel were placed on his tongue. From 
this time the dyspnoea began to abate and the patient recovered. 

The medical journals from time to time have published reports of cases 
of croup in which calomel has apparently been beneficial. Dr. J. P. Klin- 
gensmith^ of Blairsville, Pennsylvania, states that physicians in his locality 
prescribe calomel in large doses for croup, and with greater success than that 
achieved by other modes of treatment, and he relates three cases showing the 
result in his own practice : 

^Med. Record, July 12, 1SS4. 



664 MEMBRANOUS CROUP. 

Case. — A child aged twenty-eight months took twenty grains of calomel 
placed on the tongue in the commencement of croup, and afterward ten grains 
every hour till the third day, when seven hundred and twenty grains had been 
taken. It was now discontinued, and on the sixth day the pseudo-membranes 
had disappeared. Recovery was rapid and without any untoward symptoms. 

Case. — The second patient, aged three and a half years, had been sick 
forty-eight hours, with a temperature of 102° F. He had a croupy cough and a 
pseudo-membranous exudation. Twenty grains of calomel were"^ administered, 
and afterward ten grains, every hour for fifteen hours, so that one hundred and 
seventy grains were administered. The child, which had previously been restless, 
fell into a quiet, natural sleep. The calomel was discontinued, and a mixture of 
potassium chlorate and ammonium chloride given in its place. On the fifth day 
convalescence was fully established without any unfavorable symptoms. 

Case. — The third patient, a girl of four years, had been sick twenty-four 
hours, with " high temperature, painful croupy cough, labored respiration, dry 
skin, flushed face, and some diphtheritic " exudation. Twenty grains of calomel 
were administered, and followed by hourly ten-grain dose's till twelve doses 
were given. No other remedy was employed, and in three or four days the patient 
recovered. 

These appear to have been genuine cases, and that they recovered tends 
to confirm the belief that calomel does exert a beneficial action on pseudo- 
membranous inflammations, either diminishing the exudation or promoting 
the liquefaction and detachment of the pseudo-membrane. 

A mode of treatment commonly accepted and practised by the profession 
through a long series of years usually does some good, in at least a certain 
portion of cases, even if it be abused, else it would not be likely to gain 
general acceptance. We know how quickly calomel cures the mucous patches 
of syphilis even when they are of large size. These are produced by inflam- 
matory changes in the tegumcntary system, and they consist largely of 
epithelial or epidermic cells. They therefore contain elements similar to the 
pseudo-membrane in croup, but without the fibrin. We know also how 
readily fibrinous opacities on the cornea yield to calomel dusted on them. 
We may admit that calomel probably exerts a salutary action either on the 
exudative process or the pseudo-membrane, without being able to state pre- 
cisely how it acts. Bouchut says of calomel in his article on croup : '' This 
medicine promotes the expectoration and the rejection of the false mem- 
brane." Trousseau believed that the beneficial efl"ects of the mercurial 
preparations were due mainly to their local action. He states that "wher- 
ever they can be applied locally " they " modif}' most powerfully the diph- 
theritic inflammation." He dusted the inflamed surface, if accessible, with 
calomel or with a powder of the red precipitate, one part to twelve of pul- 
verized sugar. The use of the mercurial collar for the neck in the treatment 
of croup, employed and recommended by Bretonneau, is familiar to those 
who have read his memoirs. Professor Jacobi also, who has probably given 
more attention to diphtheria than any other physician in America, apparently 
believes that mercury used locally is beneficial in croup, for he has recently 
recommended inunction with the oleate of mercury upon the neck whenever 
the bichloride of mercury administered internally disagrees. It has seemed 
to me that one or two large doses of calomel administered in the commence- 
ment of croup, when there is no decided cachexia, do exert a beneficial action 
on the course of the disease, as in the following case : 

Case. — R , male, aged three years, began to be croupy, but without any 

marked impairment of the voice, on November 7, 1884. The mother states that 
he has had sore throat nearly one week, but without medical attendance. His 
respiration gradually became more noisy and difficult till the evening of the 8th, 
when I was asked to see him. 

His temperature was 99°. The dyspnoea was such that the post-clavicular. 



TREATMENT, ^65 

suprasternal, and inframammary regions were depressed on inspiration, and his 
breathing was noisy, but the voice had nearly the usual clearness. The fauces, 
though red, were not notably swollen, and a pseudo-membranous patch of the 
size of the little finger-nail fay over the right tonsil. The diagnosis was there- 
fore made of mild diphtheria, but with dangerous laryngeal stenosis, probably 
from the presence of a pseudo-membrane ; general condition of the child good. 
Six grains of calomel were placed on the tongue, and inhalation was ordered 
by the steam-atomizer of the following : 

R. Liquor potassae, 5j ; 

Aquae calcis, Oj. Misce. 

The record of November 10th states : Resp. 38 per minute, still noisy, but no 
increase of dyspnoea; pulse 126; temperature in groin 99^°; slight discharge 
from nostrils \ uses the inlialation almost constantly. From this date the pseudo- 
membrane and redness of the fauces gradually disappeared, and two days later 
the patient was out of danger. 

The results of the treatment of diphtheria and of the inflammations which 
accompany this disease are liable to produce an erroneous opinion in regard 
to the value of therapeutic agents, since cases differ so greatly in type or 
severity. But the experience of many physicians justifies the belief that 
mercury, and especially calomel, employed within certain limits in the com- 
mencement of a pseudo-membranous inflammation, does exert some control- 
ling action on this disease. That it did much harm formerly, when physicians 
prescribed it freely to the extent in many instances of increasing the cachexia 
and causing mercurialism, should not deter from its judicious use. In the 
ordinary form of diphtheria I would not advise the use of calomel, or would 
limit its employment to one or two doses of six or ten grains in the commence- 
ment of the disease in robust cases. But in croup, since the danger is not 
from the cachexia or blood-poisoning so much as from the laryngeal stenosis 
which usually develops rapidly, that medicine is indicated, and should be pre- 
scribed, which most strongly retards the exudative process and aids in lique- 
fying and removing the pseudo-membrane ; provided that it produce no dele- 
terious effect which renders its use inadmissible. Hence it is proper to 
prescribe calomel in larger doses and for a longer time in the treatment of 
croup than in other forms of membranous inflammation, if it fulfil the indica- 
tion, as it seems to in a measure. In my own practice, however, calomel is 
not prescribed after the first or second day, since I prefer the use of other 
remedial measures which are efficient and are less likely to produce injurious 
effects. It is certainly the opinion of the majority of New York physicians, 
in which I concur, that after the first day corrosive sublimate is preferable 
to other forms of mercury for internal use, inasmuch as most cases of mem- 
branous croup occur as a manifestation or complication of the microbic dis- 
ease diphtheria. 

Emetics. — These have been largely used in all forms of croup, and in 
catarrhal or spasmodic croup they usually produce marked relief. Formerly, 
emetics were much employed in the treatment of membranous croup, but 
now that diphtheria has spread throughout the country, and most cases of 
this form of croup occur in patients suffering from diphtheritic blood-poison- 
ing, depressing emetics, as ipecacuanha and antimony, have fallen into disuse, 
since they were found to be badly tolerated. In my practice a child of ten 
years with severe diphtheria and with commencing croupy symptoms sank 
rapidly and died between two of my visits, from exhaustion produced by a 
single large dose of ipecacuanha administered by anxious parents without my 
advice. 

But an emetic gives partial relief to the dyspnoea in certain cases, since it 
assists in expelling the muco-pus which blocks up the tubes below the pseudo- 



666 . MEMBRANOUS CROUP. 

membranes, and sometimes portions of pseudo-membrane, which are easily 
detached. If an emetic be employed, one should be selected which acts 
promptly with little depression, and as a rule it should, I think, only be used 
at the commencement of croup. If after the initial period there be that 
degree of dyspnoea which suggests its use, intubation is preferable as more 
likely to give relief and save the patient. Of the emetics which are admissi- 
ble in the commencement of croup, sulphate of copper is one of the best. 
Several years since, in one case in which there were at my first visit dyspnoea, 
croupy cough, and a pseudo-membrane over each tonsil, and in regard to which 
I had made an unfavorable prognosis, the parents, observing the good effects 
of two grains of sulphate of copper, repeated the dose every two to four hours 
till the following day, and the patient recovered. Such a result, however, I 
regard as exceptional. Probably in ordinary cases the best emetic is the 
yellow sulphate of mercury or turpeth mineral in a powder of two or three 
grains. The use of this emetic in croup was prominently brought to the 
notice of the profession by Prof. Fordyce Barker, who administered this 
agent immediately after being summoned to a case, and, he alleges, with 
remarkable benefit to his patient. It has, however, been recently stated on 
apparently good authority that turpeth mineral, when it enters the stomach, 
although it causes vomiting, is not itself ejected unless in small quantity, so 
that a considerable part of its action may be through its absorption, its mode 
of action being like that of calomel. 

Internal Disinfectants, or Germicide!^. — The theory which happens to pre- 
vail regarding the nature of a disease necessarily influences the treatment. 
The theory is now accepted that diphtheria is produced by a microbe, and 
hence the use of antiseptic internal remedies is proper in the treatment of 
croup when it supervenes as one of the manifestations of diphtheria. There- 
fore the most active of the germicides, corrosive sublimate, is commonly 
employed in New York, as we have stated above, in the treatment of diph- 
theritic croup, in the same manner as in other forms of diphtheria. 

Since membranous croup in localities where diphtheria prevails is in most 
instances a local manifestation of this disease, the same sustaining general 
treatment is required which is proper in ordinary cases of diphtheria. The 
tincture of the chloride of iron, administered every second hour in liberal 
doses, potassium chlorate, quinine, brandy or other form of alcohol in large 
and frequent doses, long used in diphtheria as tonics and blood-restorers, are 
indicated. Medicines of this kind may be given between those which are 
designed to correct the exudative process and aid in removing the laryngeal 
obstruction, which have been described above. The diet should be nutri- 
tious and easily digested, consisting largely of milk and the meat teas. For 
those with poor appetite and feeble digestion peptonized milk and the pep- 
tonized meat juices may often be advantageously prescribed. 

Surgical Treatment. — Although the best possible treatment by inhala- 
tions and internal medication be early employed and without intermission, 
yet it is the common experience in all countries that such treatment is in a 
large proportion of cases inadequate, and that many perish from suffocation 
unless relieved by surgical interference. We have stated above that if 
croup occur at the commencement of diphtheria, when the exudative process 
is active and the pseudo-membranes form rapidly and abundantly, death is 
the common result if the medicinal treatment only be employed. But if 
the inflammation be less intense or subacute, as in the second week in diph- 
theria, so that there is more time for the action of medicines and inhalations, 
and if, as is sometimes the case, the stenosis appear to be at a standstill, 
without any marked suffering from want of air, resort to surgical measures 
may be judiciously postponed. 



INTUBATION. 667 

The indications for surgical interference are a gradual increase of the 
stenosis and consequent dyspnoea, notwithstanding the constant and judicious 
use of remedial agents, and a manifest suiFering from want of air as shown 
by restlessness of the child and the expression of suifering in his features, 
with or without lividity of the surface. We adults may have some faint 
conception of the suffering which children with acute laryngeal stenosis 
undergo when we have severe nasal catarrh and attempt to breathe with the 
mouth closed ; and the paramount duty of the physician to relieve suffering 
should prompt to a resort to other measures when medicines prove inade- 
quate, even if we leave out of account the important object of saving life. 
When, therefore, membranous croup is found to be progressive after having 
been observed and properly treated from six to twenty-four hours, and the 
child begins to suffer from want of air, the propriety of surgical measures 
should be considered. 



CHAPTER lY. 

INTUBATION. 

The most important improvement made in recent years in the treatment 
of croup is intubation, for which the profession are indebted entirely to the 
genius and perseverance of Dr. Joseph O'-Dwyer. Intubation is destined 
in the future to prevent an immense amount of suffering in the various forms 
of laryngeal stenosis. It has rescued, and will rescue, multitudes of chil- 
dren from a most painful death by suffocation. It is an operation of remark- 
able simplicity, quickly performed, without the use of anaesthetics and with- 
out pain to the patient. In this respect it contrasts strikingly with laryn- 
gotomy or tracheotomy, which is a painful and bloody operation, and which, 
for its proper performance, requires more or less delay. Those who have 
witnessed the slow suffocation of children in membranous croup and catarrh- 
al croup when accompanied by oedema and infiltration can best appreciate the 
value of intubation. 

In 1858, Bouchut published a paper on the treatment of croup by intu- 
bation of the larynx. He employed a straight cylindrical tube nearly an 
inch long. The tube was introduced by means of a male catheter open at its 
two ends. Intubation excited some attention and discussion at the time in 
the Parisian capital, and M. Gros related a case of its successful employment. 
But, performed with such rude instruments, it met, as might be expected, 
with strong opposition from the first by such men as Barthez and Trousseau, 
who were bringing forward tracheotomy, and it soon fell into disuse and was 
forgotten. It was reserved for American surgery to achieve the honor of its 
successful employment. Dr. O'Dwyer, wholly ignorant of the previous his- 
tory of intubation, after many measurements of the larynx of the cadaver, 
many discouragements, and many modifications in the tubes to facilitate 
their introduction and retention, has so improved them that the objection to 
their use strongly urged by Trousseau thirty years ago, that they caused 
ulceration, is inapplicable to the tubes now in use. Dr. O'Dwyer has kindly 
contributed the following paper descriptive of this operation : 



668 INTUBATION. 

Intubation. 
By Joseph O'Dwyer, M. D. 

In the following pages I will confine myself to the practical details of this 
operation, as applicable to those forms of stenosis of the larynx that occur 
almost exclusively in children. The reader is referred to the appropriate sec- 
tions of this book for information in regard to the diagnosis, medical treat- 
ment, etc. of croup and kindred diseases. 

A very serious impediment to the success of intubation, and one for which 
there is no remedy, arises from the large number of grossly-imperfect instru- 
ments that are constantly being made and sold as the latest improvements. I 
will therefore first endeavor to point out some of the grosser defects referred 
to, in order that every one who uses these tubes may be able to distinguish 
the good from the bad. 

The most common defect, and at the same time the one attended with the 
most serious consequences, is apparently so insignificant that it is often over- 
looked by the manufacturers, even after their attention has been repeatedly 
called to it. It results from filing the metal so thin on the anterior surface 
of the distal extremity as to produce a cutting edge at this point. It should 
be remembered that this part of the tube is not only in contact with the ante- 
rior wall of the trachea, but that it also moves up and down over a space of 
about half an inch during every act of swallowing. This position is pro- 
duced by the backward pressure of the base of the tongue, which pushes the 
epiglottis and the upper extremity of the tube before it with considerable 
force, tilting the lower extremity forward, which glides upward as the larynx 
is raised and the trachea stretched, to fall back to what may be called its res- 
piratory position as soon as the act of swallowing is completed. 

If sharp, or even in the slightest degree rough, at the point indicated, a 
proportionate degree of injury will be inflicted on the mucous membrane, 
sometimes amounting to a deep ulcer, which adds to the danger of systemic 
infection and gives rise to painful deglutition and bloody expectoration. 

In the perfect tube the metal on the anterior surface is left quite thick 
and smoothly rounded off like the runner of a sled, so that it will glide up 
and down over the tissues without injuring them. As the distal extremity 
of the tube seldom impinges on the posterior wall of the trachea, and never 
touches the sides, the metal at these points should be comparatively thin, to 
avoid increasing the size, but the whole should form a perfectly smooth probe- 
point when the obturator is in position. If the obturator do not project far 
enough beyond the end of the tube, or if it fit imperfectly, the sharp edges 
will be left unprotected, which will injure the tissues while passing through 
the narrowed glottis. 

The metal is also left thick on the anterior surface of the upper extrem- 
ity in order to prevent the formation of a cutting edge under the epiglottis. 
The head or shoulder of the tube which rests in the vestibule of the larynx, 
and which is compressed by the action of the constrictor muscles in every 
act of swallowing, should be absolutely free from any roughness or projecting 
angles or edges. This portion of the tube, about a quarter of an inch in 
length, has a backward curve to carry it away from the base of the epiglottis, 
where a perfectly straight tube would be liable to produce ulceration. 

Another very common defect is the imperfect fitting of the obturator, 
which allows the tube to wabble when attached to the introducer, and causes 
it to slip off if the operation fail to place it in the larynx on the first 
attempt. The instrument-makers find it very difficult to overcome this defect, 
owing to the joint in the shank of the obturator and the backward curve that 
exists in the upper portion of the tube. 



INTUBATION. 



669 



If properly made, the tube when attached to the introducer and ready for 
use should be as free from motion as if constructed of one piece. 

T have also noticed in many of the sets of instruments otherwise imper- 
fect that the lines indicating the years on the scale do not correspond to the 
length of the tubes, which renders it difficult for a beginner to select the 
proper size. By observing the following rule the scale can be dispensed 
with : The smallest size is suitable for the first year of life, the second for 
the second year, and the third size for from two to four years, and the others 
for two years each. 

A set of intubation instruments suitable for children up to the age 
of puberty consists of six tubes (e), an introducer («) and extractor 
(r), a mouth-gag (b). and a scale of years (c/) ; /" introducer and tube ; 
gj a large round tube used for the expulsion of membrane. Each tube is 



^ Fig. 41. 




Intubation Instruments. 

supplied with a separate obturator, one end of which screws on to the 
introducer, while the other extends sufficiently beyond the distal extremity 

1 Geo. Ermold, 204-206 East Twenty-third Street, New York. 



670 INTUBATION. 

of the tube to convert the whole into a probe-point. The numbers on the 
scale represent years, and indicate approximately the ages for which the 
corresponding tubes are suitable. For example, the smallest size when 
applied to the scale, including the head or shoulder, will reach the line 
marked 1, and is suitable for the first year of life, but may be used up to 
fifteen or eighteen months if the child be small for its age. 

The next size, which reaches the line marked 2, is intended for children 
between one and two years, but may be used up to three years, the onl}^ 
objection being that it is liable to be coughed out. The third size, marked 
3-4 on the scale, should be used between the ages of two and four years ; 
and so on. 

The largest tube in the set may be used in the early years of adolescence 
by having a string attached, but is of no use in the adult larynx, as it would 
either be expelled immediately or pass through into the trachea. 

When the proper tube for the age is coughed out, there is always room for 
the next larger size. In one case, of an infant aged twenty months, in which 
the two-year-old tube was twice expelled, I was obliged to insert the 3-4 size. 

Indications for Intubation. — As the indications for this operation are the 
same as for tracheotomy, the reader is referred to the proper section of this 
work for information on this subject. 

Method of Operating. — A tube of proper size for the age is first selected, 
and strong silk or linen thread passed through the eyelet intended for this 
purpose. In case the tube is placed in the oesophagus instead of the larynx, 
it quickly passes into the stomach, drawing the string with it, unless the 
latter be held. To guard against this accident, therefore, the thread should 
be left long enough to reach the stomach and still protrude from the mouth. 

The obturator is then screwed tightly to the introducer and passed into 
the tube when it is ready for use. The antero-posterior or long diameter of 
the tube should then be in a line with the handle of the introducer. If the 
obturator be found to turn too far to bring it in this position, which usually 
occurs after having been used for some time, a washer of writing-paper of 
one or more thicknesses can be added. 

It is always advisable to push the tube off once or twice before inserting 
it, to be certain that it works easily. The person who holds the child should 
be seated on a solid chair with low back, and the patient placed on the lap 
with its head resting on the left shoulder of the nurse, to avoid interference 
with the gag. The hands may either be held or secured by the sides by pass- 
ing a towel or napkin around the body, and retained in that position until the 
tube is inserted and the string removed. Failure to pay particular attention 
to this precaution is often the cause of much annoyance to the operator, for 
if the child gets its hands free for an instant, it seizes the thread and removes 
the tube. Fastening the hands in front of the chest or thick garments in 
the same location are objectionable, as they render it difficult to depress the 
handle of the introducer sufficiently to carry the tube over the dorsum of 
the tongue. 

The gag should be inserted in the left angle of the mouth, well back, 
between or behind the teeth if practicable, and opened as widely as possible 
without using too much force. In children who have not at least one double 
tooth on the left side the gag should not be used, as it slides forward on the 
gums, and, besides being in the way, is likely to injure the incisor teeth. 
There is little difficulty in keeping the mouth sufficiently open with the finger, 
and no danger of being bitten if it be kept well to the patient's right. The 
necessity of using force is obviated by allowing the child to compress the 
finger for a few seconds until the jaws relax, before carrying back into the 
pharynx. The Denhard gag, which is shown in the cut, holds better than 



INTUBATION. 671 

the one originally devised by tlie author, and seldom slips if properly 
placed. 

An assistant, standing behind, holds the head firmly by placing one hand 
on either side, and, if without experience, should be requested not to touch 
the gag. The operator, either standing or sitting in front of the patient, the 
former position being preferable, holds the introducer lightly between the 
thumb and fingers of the right hand, with the thumb resting just behind the 
button that serves to detach the tube, and the index finger in front of the 
trigger-support underneath. Held in this position, it is impossible to use 
force enough to make a false passage, while if firmly grasped in the hand the 
beginner is very liable to lacerate the tissues. 

The index finger of the left hand is now quickly passed well down in the 
pharynx or beginning of the oesophagus, and then brought forward in the 
median line, raising and fixing the epiglottis, while the tube is guided beside 
the finger into the larynx. 

If any difiiculty be experienced in feeling the epiglottis, it is better to 
seek the cavity of the larynx, a cul-de-sac into which the tip of the finger 
readily enters, and which cannot be mistaken for anything else. Once in this 
cavity, the epiglottis must be in front of the finger, and the latter is then 
raised and carried to the patient's right in order to leave room for the tube 
to pass beside it. As the larynx contracts when touched, thereby diminish- 
ing its aperture, it is necessary to keep the distal extremity of the tube close 
to the finger, or even directing it a little obliquely to the right in order to get 
inside the left aryepiglottic fold. This is particularly important in very young 
children, in whom the tip of the finger completely covers the larynx. 

In the beginning of the operation the handle of the introducer is held 
close to the patient's chest, and rapidly raised as the lower end of the tube 
passes behind the epiglottis ; otherwise, it slips over the larynx into the 
oesophagus. 

When the tube is inserted, it is slipped off by pressing forward the button 
on the upper surface of the handle with the thumb, while counter-pressure 
is made by the index finger underneath. In removing the obturator the tube 
must be held down by placing the finger either on the side or posterior por- 
tion of the shoulder. The tube should be carried well down before being 
detached, otherwise it is liable to become occluded with false membrane when 
subsequently pushed home with the finger. When the tube is in place the 
gag is removed, but the string is allowed to remain for about ten minutes, 
or until it is ascertained with certainty that the dyspnoea is relieved and that 
no loose membrane is present in the lower portion of the trachea. 

In removing the thread the finger must be reinserted to hold the tube 
down, but the reinsertion of the gag is rarely necessary for this purpose. 
The extraction of the tube is much the most difficult operation, and at the 
same time the most dangerous as far as injury to the larynx is concerned. 
The patient is held in the same position as for insertion, and the extractor is 
guided along beside the finger, which is first brought in contact with the head 
of the tube, and then carried to the right in order to uncover the aperture and 
leave room for the instrument to enter beside it. 

Before inserting the extractor it should be ascertained with certainty that 
the tube is still in the larynx. This can be determined by the tubal charac- 
ter of the cough, which is characteristic, the difficulty of swallowing, and, 
lastly, by the sense of touch if necessary. 

Dijficalties of the Operation. — Few who have not practised intubation 
recognize the fact that it is a difficult operation to perform, and that it is 
difficult simply because it must be done quickly and at the same time gently. 
Sufficient dexterity to fulfil both of these requirements can only be acquired 



672 INTUBATION. 

by a great deal of practice, and if this be gained on the living subject it must 
be at the expense of a great deal of unnecessary suffering and the sacrifice 
of many lives as well. It is the sense of touch alone that is to be relied 
upon, and that requires to be educated; consequently, the accomplished 
laryngologist who has only educated his sense of sight is no more competent 
to perform the operation than one who has never seen the larynx in its nor- 
mal position. 

The operator has so many movements to make, involving both hands, in 
such a brief space of time, that unless he have had sufficient practice to make 
some of these movements to a certain extent automatic, he cannot operate 
with safety to his patient nor with credit to himself. The epiglottis must be 
found, raised, and held in this position as the tube is glided down in contact 
with the finger, otherwise the operator does not know where it is ; it has to 
be slipped off at the right moment, and held down while the obturator is 
being removed ; and to be safe all these movements must be completed in less 
than ten seconds. 

Intubation should therefore never be attempted, except in case of emer- 
genc}^, without some preliminary practice, either on the cadaver, on one of the 
smaller animals, or on a larynx removed from the body. Let the beginner 
who has never performed either operation choose tracheotomy rather than 
intubation as being the safer, because in the former he can see what he is 
doing and his patient can breathe during the progress of the operation. Prac- 
tice on a child's cadaver is within the reach of comparatively few, but it can be 
done on that of one of the smaller animals, such as a cat or dog, with prac- 
tically the same result — viz. education of the sense of touch and automatism 
in some of the movements. 

In addition to a moderate amount of this kind of practice, every young 
operator should keep a small larynx in preservative fluid on which he can 
continue to practise at frequent intervals by placing it upright in the neck 
of a bottle or other receptacle in the same relative position which it occupies 
in the body. 

There is no doubt that dexterity in the use of these instruments can be 
acquired in this manner ; and this is particularly important in extracting the 
tube, which is so difficult to do without injuring the larynx. 

The difficulty sometimes experienced in intubating older children who 
offer resistance is to a great extent obviated by placing their legs between 
the knees of the person acting as nurse and holding them firmly in that 
position. 

Accidents and Dangers of Intubation. — The most serious of the avoidable 
accidents attending this operation is asphyxia, from holding the finger too 
long in the throat. It should be remembered that when intubation is called 
for the patient is getting very little air, and can afford to dispense with this 
little only for a very short time without danger to life. After the insertion 
of the gag an expert can, as a rule, place a tube in the larynx in five seconds 
or less, and without any shock worth considering. The novice, on the con- 
trary, having so many other things to occupy his attention, is very liable 
to forget how long his finger has been in the throat, and that during this 
time respiration is practically suspended. A fatal issue under these circum- 
stances is almost invariably attributed to pushing down membrane, which 
is not a common accident, and has never proved immediately fatal in my 
hands. 

There is seldom any danger from repeated failures to intubate, pro- 
vided the finger be not retained in the pharynx longer than ten seconds 
at a time, and the child be given a chance to get its breath between the 
attempts. 



INTUBATION. 673 

It is well for the beginner always to have another physician present, 
who while holding the head will watch the patient closely and be prepared 
to give some prearranged signal to stop when he thinks there is danger of 
asphyxia. 

The ventricles of the larynx seldom offer any obstruction to the entrance 
of the tube, as they are usually obliterated by the swollen mucous mem- 
brane and covered over by the fibrinous deposit in croup ; but this should be 
remembered if any resistance be encountered, as it does not require much 
force to make a false passage at these points. 

Pushing down a mass of pseudo-membrane before the tube is the most 
serious of the unavoidable accidents attending intubation in croup. In the 
majority of cases the oflFending membrane is expelled on the withdrawal of 
the tube, if the latter be inserted quickly and as quickly removed when the 
respiration is found to be suspended ; and even if none be expelled the 
patient is in no worse condition than he was in before the operation. 

I have devised and tried various instruments for the removal of pseudo- 
membrane from the trachea, but I have found short cylindrical tubes of large 
calibre the most successful. Being short, they do not accumulate masses of 
membrane before them, and, while overcoming the obstruction in the glottis, 
afford relief to the dyspnoea where the long tubes fail. They are only 
intended for temporary use, as, owing to their large size, extensive ulcera- 
tion would result if long retained. The string should be left attached and 
secured behind the ear, by which the tube can be removed at the end of four 
or five hours whether any false membrane be expelled or not. The amount 
of dilatation from the pressure accomplished in this time will usually secure 
several hours of relief from dyspnoea and give ample time for the physician 
to reach the patient and reintubate, if necessary. Should the offending 
membrane still be retained, it is better to use the same tube on the recur- 
rence of dyspnoea than to again run the risk of producing apnoea by insert- 
ing the long one ; otherwise the latter is preferable. 

These tubes (Fig. 41, ^) have no retaining swell, the size alone being 
sufficient to retain them. The metal of which they are constructed is made 
very thin, in order to have as large a lumen as possible, and they can also be 
used to facilitate the expulsion of foreign bodies from the lower air-passages. 
Under these circumstances they can be left in position for a much longer 
time without danger from pressure, because the mucous membrane of the 
larynx is in the normal condition. 

A separate introducer with long curve is necessary for these tubes in 
order to carry them well through the subglottic division of the larynx before 
removing the obturator. 

Danger of Asphyxia from. Loo^e Memhrane heloiu the Tube. — The ex- 
istence of loose membrane below the tube — that is, in the lower portion of 
the trachea — usually gives rise to the following signs : A flapping sound with 
the respiratory movements, a hoarse or croupy character of the cough, and 
obstructed aspiration, especially when forced, as in the act of coughing. In 
some cases there is no difficulty while the breathing is quiet, but the egress 
of air is completely cut off with the first attempt at coughing. The vu a 
tergo thus developed is often sufficient to cause the expulsion of both tube 
and pseudo-membrane, but this does not alw^ays occur, and precautions should 
be taken to avoid the danger of sudden death from this cause. 

The safest plan is to leave a string attached, by which any one who is pres- 
ent can remove the tube in case of threatened asphyxia. Should this not be 
practicable, owing to the age or from other causes, a smaller tube than that 
indicated by the scale of years should be used, which would be more likely to 
be couo;hed out in the event of its sudden occlusion. Either of these methods 



674 INTUBATION. 

should be resorted to if tlie symptoms of loose membrane in the lower part 
of the trachea, absent at the time of operation, subsequently show them- 
selves. 

Premature expulsion of the tube seldom occurs when the proper size has 
been used, and is rarely attended with danger, pro.vided the patient be within 
easy reach. 

Dangers of Extraction. — Cases have been reported in which the tubes as 
now made, with large heads, have passed through into the trachea. This 
accident can only occur when the tissues of the larynx, cartilages included, 
have been extensively lacerated by the extractor by passing it down on the 
outside of the tube and withdrawing it with force. This danger has been 
minimized to a great extent by the addition of a regulating screw to the 
extractor, which prevents the blades from opening any wider than is necessary 
to hold the tube firmly. 

No force is necessary to remove a tube from the larynx, and if any 
appreciable resistance be encountered, it is pretty certain that the instrument 
is caught in the tissues. Severe hemorrhage often results from a very moder- 
ate laceration produced in this manner. 

When the Tube should be Removed. — In a large number of recoveries 
following intubation in croup the average time the tube was retained 
amounted to five days. The longest time in my own practice was twenty- 
nine days. The older the child, as a rule, the sooner it can be dispensed 
with. In very young children, when progressing favorably or if the patient 
be not within easy reach, it is better to leave it in position for seven or eight 
days. The frequent removal of the tube, unless specially indicated by a 
recurrence of the dyspnoea or for other cause, is bad practice, principally 
because of the irritation produced on each occasion. In protracted cases, in 
which the dyspnoea returns soon after the second or third removal at regular 
intervals of four or five days, it is safer to leave it in position continuously 
for two or three weeks, unless some special indication for its removal arises 
in the interim. If the tube be properly constructed and well plated, it will 
do no harm when retained for this length of time. 

Management after Intubation. — One of the greatest advantages of intuba- 
tion over tracheotomy is the fact that no skilled nursing is required after the 
operation. The most important part of the after-treatment -consists in getting 
the patient to take a sufficient amount of nourishment. The difficulty here- 
tofore experienced in this matter has been greatly reduced by the method 
suggested by Dr. W. E. Casselberry of Chicago. It consists in feeding while 
the patient's head is lower than the body. By this means advantage is taken 
of gravitation, thus allowing any fluid that may have entered the tube to 
escape without the act of coughing. The little patient soon learns this, and 
ceases to object to the uncomfortable position. For very young children at 
least the best position is lying on the back across the lap, with the head 
hanging well below the level of the body, and feeding from a spoon or bottle. 
Older children may be allowed to assume any position they wish, provided 
the head be lower than the chest. 

Feeding in the upright position should always be by spoon, at least for 
the first two or three days, and the patient be given time and encouraged to 
cough between the acts of swallowing. By this means any danger from the 
entrance of food is obviated. Nourishment in the solid and semi-solid forms 
- — which are swallowed better than liquids — should be given the preference 
when children can be induced to take them. 

Rectal feeding is rarely necessary, but when resorted to should be given 
in small quantities — not over two ounces — and at intervals of three or four 
hours. 



TRACHEOTOMY. 675 

No food or medicine should be given for two or three hours after intuba- 
tion, unless the presence of the tube fail to excite sufficient cough to get rid 
of accumulated secretions. It is principally by the act of coughing that the 
tube is kept clear, and if this does not occur voluntarily, it may be excited 
by giving some irritating substance, such as carbonate of ammonia, brandy 
strong or slightly diluted, etc. If this plan be adopted and the air of the 
room be kept well saturated with warm vapor, it will rarely be found neces- 
sary to remove a tube for the purpose of cleaning it. The presence of a 
tube in the larynx does not contraindicate the use of an emetic, which is 
sometimes necessary when the bronchi are loaded with secretions. 

Tracheotomy. 

Prior to the employment of intubation by O'Dwyer, tracheotomy was 
one of the most important operations in surgery. Properly performed and 
at the proper time, with judicious after-treatment, it has rescued many chil- 
dren from a most painful death. The details of this operation are given in 
surgical treatises, but some general remarks relating to it will not be inap- 
propriate here. 

Sanne says that the operator should have three assistants, at least one of 
them a physician. One should administer chloroform, one use the sponge, 
and the third, a physician, should be ready to assist in handing instruments, 
ligating vessels, etc. The operation is simple and devoid of danger, or 
difficult and dangerous, according to circumstances. The younger the child, 
the greater the danger, other things being equal. The greatest difficulty and 
risk attend tracheotomy in fleshy infants with thick and short necks and in 
patients who have extreme dyspnoea and are nearly moribund, so that the 
operator is compelled to hurry in the operation through fear that death will 
occur before the trachea is opened. The operator should have time for slow 
and cautious dissection, that he may avoid wounding vessels and other import- 
ant parts. 

The patient to be operated on should be placed on his back on a table 
covered by a blanket, and a bottle or block aboat four inches in diameter 
should be placed under his neck, so that the head is thrown back at an angle 
of forty-five degrees and the anterior surface of the neck rendered prominent. 
Chloroform is then administered. An incision should be made through the 
skin in the median line one and a half to two inches in length, according to 
the age, and extending to within half an inch of the sternum. Through the 
connective tissue to the trachea the dissection should be slowly and cautiously 
made with the point of the knife, the scissors, and the blunt hooks which are 
used to tear the connective tissue and draw aside vessels. The tip of the 
finger occasionally pressed upon the trachea aids in determining its location 
and serves to guide the dissection, which should always be in the median 
line. Little cutting is required after the skin has been divided, but when 
fibres of connective tissue resist the blunt hooks they should be cut either 
by the point of the knife or the scissors. A grooved director is also useful 
in the dissection, since by it the operator is enabled to raise and tear resisting 
fibres or detach them from parts underneath so that they can be more readily 
divided. 

Some surgeons prefer the high, others the low operation. In the high 
operation the trachea is found nearer the surface, and the vessels in the way 
are less numerous than in the low opei'ation. In the operation, however, the 
trachea is usually opened at that point, whether high or low, which is most 
readily reached and laid bare. When this tube is exposed a longitudinal 
incision is made through its anterior wall sufficiently long to allow the canula 



676 INTUBATION. 

to be inserted. To facilitate opening the trachea it may be held by a tenaculum 
constructed for the purpose, with the hook bent so as to be at right angles 
with the handle. The length of the incision through the trachea should be 
about five-eighths of an inch. The canula should not be immediately intro- 
duced, but the patient should be made to cough by inserting a pigeon's quill 
down the trachea into the bronchial tubes. Blood, muco-pus, and shreds of 
fibrin, if any be present, are expelled through the opening by the cough which 
the quill produces. The canula is now introduced, with or without the aid 
of the tracheal dilator. The one which is in common use is that devised by 
Trousseau, with some subsequent improvements. It consists of two concen- 
tric cylinders, the external fenestrated, and the disc or plate which supports 
the tubes is movable upon them. 

The result depends to a great extent on the subsequent treatment. The 
common result is immediate relief to the dyspnoea, but unfortunately, in a 
large proportion of cases, the temperature rises about the third day after the 
operation and pseudo-membranes begin to form in the bronchial tubes, and in 
some instances broncho-pneumonia results. Surgeons have endeavored to 
prevent the formation of membranes in the bronchial tubes after tracheot- 
omy by allowing lime-water to trickle through the aperture into the tubes. 
Perhaps some other solvent of pseudo-membranes, as bicarbonate of soda or 
trypsin, might be preferable for this purpose. No surgical operation more 
imperatively requires intelligent and attentive after-nursing than tracheotomy, 
since the canula needs to be frequently removed and cleaned whenever ob- 
structed by muco-pus. No certain time can be foretold for the removal of 
the canula if the patient live. If on withdrawing the inner tube and apply- 
ing the finger over the end of the remaining canula the patient breathe easily 
through the fenestra, the laryngeal stenosis has probabl}^ so far abated that 
the tube can be safely removed. 

The following is a description of the instruments in the tracheotomy case 
of one of the most skilful operators in New York City, Dr. Fred. Lange ; all 
of them have small handles like those of dental instruments: 

1. a. A scalpel with cutting edge convex, the blade 1^^ inches in length 
and its greatest width J inch. The scalpel is employed in dividing the skin 
and in subsequent dissection, h. A scalpel of same length, but with narrower 
blade and straight cutting edge, used for opening the trachea. 

2. Two blunt hooks, with the hook straight, \ inch in length, extending 
at a right angle from the handle, having a diameter scarcely larger than a 
carpet needle. The end of the hook is slightly bulbous. A considerable 
part of the dissection is performed by the blunt hooks, which are used in 
tearing the connective tissue. 

3. Three artery clamps, by which bleeding vessels or oozing surfaces are 
seized, and the instruments with their points attached to the bleeding surfaces 
are dropped upon the sides of the neck. They thus aid in drawing open the 
wound. 

4. Tenacula : Two with hooks in line with the handle ; two others with 
hooks at right angles to the handle ; the diameter of the curves in the hooks 
\ inch. Those with hooks at right angles are employed for transfixing- and 
holding the treachea when it is to be opened. 

5. Two grooved directors, one with the end smaller and more pointed than 
that of the other. 

6. A common artery-forceps, also forceps with fine teeth. 

7. The spring hook of the oculist, employed by him in separating the eye- 
lids ; it holds apart the edges of the wound. 

8. The tracheotomy-tube, consisting of two concentric cylinders, described 
above. 



^BBONCHITIS. b"77 

9. Pigeon's quills ; these are important for removing muco-pus and fibrin- 
ous shreds from the trachea and bronchial tubes. An instance has come to 
my knowledge in which the physician who assumed charge of the case after 
the operation attempted to use for this purpose a small piece of sponge held 
by forceps ; he unfortunately loosened his hold, and the sponge, drawn in with 
the breath, produced immediate death by suffocation. This would not have 
happened with the pigeon's quill. 

When the operation is completed and the canula introduced, iodoform 
should be dusted upon the wound, and two thicknesses of linen soaked with 
the solution of bichloride of mercury, 1 part to 2000, notched so as to sur- 
round the canula and pass under its plates, should be applied over the wound, 
and every hour moistened with the bichloride solution. With such treatment 
the wound preserves a healthy appearance and heals readily. 



CHAPTER V. 

BEONCHITIS. 

Inflammation of the bronchial tubes, or bronchitis, is probably the most 
frequent disease of early life. It is usually associated with more or less 
inflammation of the mucous membrane of the nostrils, larynx, and trachea. 
We designate the disease coryza, laryngitis, or bronchitis, according as one or 
the other inflammation predominates. Sometimes bronchitis occurs with but 
slight inflammation elsewhere, and often the coryza and laryngitis abate while 
the bronchitis is still active. 

Bronchitis occurs both as a primary and secondary disease. The secondary 
form is common in connection with measles, whooping cough, pneumonia, and 
pulmonary phthisis, and it is not uncommon in remittent and continued fevers. 
Bronchitis is acute, subacute, or chronic, and according to its extent it is mild 
or severe. If the smallest bronchial tubes are involved, the inflammation is 
designated capillary bronchitis — a term not well chosen, but which is conve- 
niently employed in a description of the malady. Bronchitis is commonly 
bilateral, aff'ecting the tubes on the two sides with about equal intensity. 
When due to tubercles or to pneumonia it is often unilateral, being confined 
to those tubes or nearly to those which lie in the tubercular or inflamed pul- 
monary tissue. 

Causes. — The causes of secondary bronchitis are obviously the diseases 
in connection with which it occurs. The cause of primary bronchitis is the 
same as that of simple acute laryngitis or coryza — namely, sudden change of 
temperature from warm to cold, exposure to currents of air, the practice of 
sending children without sufiicient clothing from heated rooms into the open 
air, the throwing ofl" of bedclothes at night, etc. 

Anatomical Characters. — In the most common form of bronchitis the 
larger bronchial tubes only are afl"ected. They are the seat of the inflamma- 
tion in most of those cases which are designated " colds " by families, and 
which are often treated without the aid of the physician. The lining mem- 
brane of the bronchial tubes presents the ordinary anatomical characters of 
mucous inflammations. It is reddened uniformly or in patches, intensely or 
in that milder degree known as arborescence, according to the severity of the 
inflammation. 

The secretion of the muciparous follicles is at first arrested and the sur- 



678 BRONCHITIS. 

face of the membrane is dry. In the course of a day or two the secretory 
function is re-established, and the surface is covered with thin and transpa- 
rent mucus. A day or two later the secretion becomes thicker, consisting of 
mucus and pus. Mixed with these substances are epithelial cells, which are 
exfoliated in abundance from the inflamed surface. At the same time the 
mucous membrane becomes thickened and more or less softened. If the 
inflammation be severe the vessels of the submucous connective tissue are 
also injected. 

Usually, in about a week in the young child, in from one to two weeks in 
older children, the inflammation begins to abate. Gradually the inflamed 
membrane returns to its normal consistence, thickness, and vascularity, and 
with this return to the healthy state the muco-purulent secretion abates. 

In this, which is the simplest and most common form of bronchitis, there 
is no ulceration, and rarely any pseudo-membranous formation if the disease 
be idiopathic. Pseudo-membranous bronchitis is not unusual as an accom- 
paniment of pseudo-membranous laryngo-tracheitis. 

Were bronchitis limited to the larger bronchial tubes, it would indeed be 
a simple affection, but, unfortunately, it has a tendency to extend downward. 
Commencing in the larger, it gradually invades the smaller tubes in a similar 
manner to the extension of erysipelas upon the skin. More rarely the inflam- 
mation commences simultaneously in the larger and smaller tubes. The grav- 
ity of bronchitis is proportionate to the degree of its extension downward. It 
may stop at any point in its progress, but if it reach the smaller tubes it is 
one of the most serious affections of early life. 

The mucous membrane of the minute tubes, those next to the air-cells, is 
delicate, with but little submucous connective tissue, and it frequently, at 
post-mortem examinations, does not present to the eye those distinct inflam- 
matory changes which are observed in tubes of large diameter. It is some- 
times not notably thickened nor its vascularity much increased, even when 
there is reason to believe from the symptoms that it was the seat of active 
phlegmasia. As we pass from these minute tubes to those of larger calibre 
the inflammatory lesions become more distinct. The inflammation produces 
minute and abundant points of redness and the membrane is evidently thick- 
ened ; often it is rough or granular. 

The minute bronchial tubes are very small, especially under the age of 
three years, and, since in capillary bronchitis a large proportion of them are 
inflamed, the source of the danger is apparent. It is with difliculty that 
the patient with capillary bronchitis can by the effort of coughing free the 
tubes from the secretions which are constantly collecting in them. In 
weakly children under the age of two years expectoration is most dif- 
cult, and hence the great and increasing dyspnoea from which such patients 
suffer. 

In severe and unfavorable cases of bronchitis, which are chiefly those in 
which the small as well as large tubes are inflamed, the following anatomical 
changes commonly occur : The muco-purulent secretion, which is tenacious, 
collects more rapidly in the smaller tubes than it is expectorated by the child, 
whose strength begins to be exhausted. The accumulation of the secretion 
is chiefly in the tubes which lie in the posterior and inferior portions of the 
lung. As the obstruction from the muco-pus increases in these tubes, less 
and less air passes through them into the alveoli, with which they communi- 
cate, while the quantity of air which passes through the unobstructed tubes 
into the anterior and superior portions of the lung is proportionately increased. 
The effect, as regards the state of the lung, is obvious. In cases having a 
fatal issue, and in which we are therefore able to inspect the lesions, we find 
that the lower and inferior portions of the organ, from which air was to a 



ANATOMICAL CHARACTERS. 679 

greater or less extent excluded, have a diminished crepitation ; that they lie 
a little below the general level, or that certain lobules do ; and that they pre- 
sent a congested appearance, for while they contain too little air, they have 
an excess of blood. We shall also find that the upper and anterior parts of 
the organ, perhaps the entire upper lobe, contain more than the normal quan- 
tity of air, so as to rise above the general level. There is distension of the 
alveoli in these parts, so that they are probably visible to the naked eye, 
and may appear to be emphysematous ; but this is a state distinct from 
emphysema. It is merely an inflation of the alveoli to nearly their full 
capacity. 

Here and there. in the portion of lung in which the inflation has been 
incomplete, lobules may be observed which are entirely collapsed, having a 
dusky-red color and no crepitation ; while in other parts, if the bronchitis 
have continued some days, there are nodules of pneumonia. Often when 
the bronchitis is severe the inflammation, commencing in the bronchial 
tubes, extends to the lungs, usually to lobules, in the lower lobes, constitut- 
ing broncho-pneumonia. The occurrence of pneumonia is announced by 
an aggravation of symptoms, and frequently by the expiratory moan. The 
incised surface of those portions of the lung to which the access of air has 
been prevented, whether they are collapsed fully or partially or not, has a 
reddish color from congestion and is moist from serum and blood. On com- 
pressing the lung the muco-purulent secretion appears upon the surface in 
points, having escaped from the divided ends of the tubes. (For other facts 
relating to atelectasis the reader is referred to the chapter in which this mal- 
ady is described.) 

Exceptionally, even when not accompanied by laryngeal croup, fibrinous 
exudation occurs in the bronchial tubes, forming a delicate film here and 
there, and readily detached from the surface underneath, while in rare 
instances it occurs as a firm and continuous membrane, forming a mould 
of the tubes, increasing greatly the dyspnoea constituting a true bronchial 
croup. If the patient with severe bronchitis survive, the inflammation of 
the mucous membrane soon begins to abate. The tubes which have been 
the seat of the disease and the alveoli which have been secondarily involved 
may return to their normal state almost immediately ; but in other instances 
such anatomical changes occur in them, even when there is no pneumonia 
nor atelectasis, that full restoration to their normal state is necessarily some- 
what slow. When the function of a lobule ceases, as it does when the tube 
leading to it is obstructed, not only hyperaemia occurs, with or without col- 
lapse, as already stated, but its cells and nuclei, and perhaps other parts, 
begin to undergo fatty degeneration. These elements become granular, 
somewhat enlarged and opaque, and here and there mixed with them are 
other large cells filled with oil-globules. These are the compound granular 
cells of pathologists, and, occurring in this situation, are produced by meta- 
morphoses of the epithelial cells. They are epithelial cells which have pro- 
gressed more rapidly than others in fatty degeneration, having reached that 
stage of it which immediately precedes liquefaction. We often with the 
microscope observe not only these corpuscles, but their fragments as they are 
dissolving. 

Minute abscesses, usually directly under the pleura, have occasionally 
been observed at the autopsies of those who have recently had general bron- 
chitis, and pathologists are not agreed as to the mode in which they are pro- 
duced. , Some of them, if not all, are evidently connected with the minute 
bronchial tubes, and the quantity of pus contained in each is not usually 
more than one or two drops. The most reasonable view of their causation is 
that they are produced in the terminal tubes where the mucus and pus col- 



680 BRONCHITIS. 

lect. The pus acts as an irritant and causes inflammation, and the inflamma- 
tion increases the quantity of pus. The walls of the tube which is now the 
seat of an abcess are destroyed by ulceration, and probably also some of the 
contiguous air-cells. The little cavity is soon surrounded by a delicate mem- 
brane, the same in character, though less thick and firm, as that which con- 
stitutes the walls of larger abscesses. The pus presents the usual appear- 
ance of this liquid, or it may be tinged by the presence of blood-cells, or. 
again, it may be thick from partial absorption of the liquor puris so as to 
resemble softened tubercle. 

The abscess is ordinarily located in the centre of a collapsed lobule. In 
certain cases it approaches the surface of the lungs, so as to produce circum- 
scribed pleurisy, with adhesion of the costal and visceral pleura. At the 
autopsy of such a case, on separating the adhesions and attempting insuffla- 
tion the air passes through the aperture, so that the lung on that side can- 
not be inflated unless the aperture be closed. Occasionally pneumothorax 
results from opening of the abscess into the pleural cavity. 

In severe protracted bronchitis dilatation of certain of the bronchial tubes 
sometimes results. The alveoli in the upper lobes may also be distended 
beyond their physiological capacity, so as to produce emphysema, but, as we 
have stated above, their maximum distension within physiological limits 
must not be mistaken for emphysema. Emphysema in the upper lobes is 
common in feeble young children with relaxed and weakened tissues, occur- 
ring even without any severe disease of the respiratory organs. It may be 
vesicular or interstitial. If it be interstitial, the sacs of air often attain 
considerable size, lying as wedges between the alveoli or like little bladders 
upon the surface of the lung. It is not difficult to understand how emphy- 
sema occurs in severe bronchitis, since the air partly arrested in the tubes 
leading to the lower lobes enters the upper lobes in increased volume and 
force. 

Symptoms. — It is evident, from the description which has been given of 
the anatomical characters of bronchitis, that its symptoms vary greatly in 
severity in difi'erent patients. It usually commences with more or less cory- 
za. The symptoms are headache, flushed face, elevation of temperature, 
acceleration and fulness of pulse. In the mildest cases these symptoms are 
scarcely appreciable. The child is observed to sneeze and have some deflux- 
ion from the nostrils, and this is followed by an occasional mild, almost pain- 
less cough, which declines in the course of a few days. The respiration and 
pulse are scarcely accelerated and the appetite is but slightly impaired. 
There may be a little fretfulness, but the child is not confined to his bed or 
room and usually amuses himself with his playthings. Auscultation in 
these mild cases reveals coarse mucous rales in the larger bronchial tubes, 
while the smaller tubes are free from mucus. Sibilant and sonorous rales 
are also observed, especially in the commencement of the bronchitis, at 
which time the secretion of mucus is suppressed or scanty. The cough in 
the commencement is for the same reason dry. It becomes looser by the 
second or third day, the sputum consisting of frothy mucus, with the admix- 
ture of pus and epithelial cells. The pus becomes more abundant as the 
disease continues. Expectoration from the mouth does not usually occur till 
after the age of four or fi've years ; under this age the sputum is ordina- 
rily swallowed. 

The mild form of bronchitis described above, that in which only the 
larger tubes are aff'ected, is common in infancy and childhood, but bronchitis 
of a non-severe type is also common, due to extension of the inflammation. 
It has already been stated that there is a tendency in bronchial inflam- 
mation to extend downward, and symptoms are proportionate in gravity 



SYMPTOMS. >681 

to the degree of this extension. In severe bronchitis the pulse rises to 
120 or 130 per minute, and the respiration is in a corresponding degree 
accelerated. The cough is frequent and painful, the pain being referred to 
the sternum, and often there is a steady dull pain in this region. The face 
is flushed and indicative of suffering, the temperature is considerably ele- 
vated, and the appetite is greatly impaired or lost. There is frequently an 
exacerbation of symptoms in the latter part of the day. Depression of the 
inframammary region during inspiration and dilation of the alse nasi accom- 
pany grave attacks of the inflammation. 

Auscultation in severe bronchitis reveals the presence of rales in all 
parts of the chest, sibilant and sonorous sparingly, coarse mucous and sub- 
crepitant more abundantly. 

General bronchitis or suffocative catarrh, the most dangerous form of this 
inflammation, is less frequent than bronchitis which is limited to the larger 
tubes or to the larger tubes and those of medium size. It may commence 
quite abruptly, but ordinarily it results from the milder form of the disease. 
The symptoms at first are such as occur in the common form of bronchial 
inflammation, but, instead of abating or remaining stationary, they grad- 
ually increase in severity till suddenly marked dyspnoea supervenes. The 
inflammation has now reached tlie minute tubes, and what promised to 
be an ordinary attack of bronchitis becomes one of great severity and 
danger. 

The respiration in severe bronchitis is short and hurried. Sixty to eighty 
inspirations per minute are not infrequent, while the pulse also is greatly 
accelerated, attaining as high a number as 140 to 160 or 180 beats per minute. 
The cough is frequent, and the sputum, which collects in abundance, is 
expectorated with difficulty. If expectorated so as to be examined, it is 
found to consist largely of frothy mucus with epithelial cells. After a few 
days, if the patient live, it becomes more purulent. Sometimes, as in bron- 
chitis of the adult, streaks of blood appear upon the mucus. In the first 
days of severe acute bronchitis the temperature is considerably elevated, the 
face flushed, and the breathing oppressed. The patient is restless, moving 
from one part of the bed to another, seeking in vain for relief. The diges- 
tive function is impaired, as in all severe inflammations ; the tongue is moist 
and covered with a light fur ; the appetite is nearly or quite lost. The 
infant takes the breast with difficulty, frequently relinquishing it on account 
of the dyspnoea ; older children take no solid food in consequence of the ano- 
rexia and the dyspnoea, and even drinks are swallowed hastily and apparently 
without relish, since deglutition interferes with respiration. On auscultation 
in bronchitis of the minute tubes sibilant, and after a day or two subcrepi- 
tant, rales are observed in every part of the chest. Percussion elicits a 
good resonance unless the substance of the lung have become involved. As 
the disease approaches a fatal termination the pulse becomes greatly acceler- 
ated ; the respiration is also in a corresponding degree frequent and panting, 
the inspiration being accompanied by increased inframammary depression 
and dilation of the alas nasi. The face becomes pallid, the prolabia livid, and 
the tips of the fingers livid and cool. The mucus and pus, accumulating in 
the air-passages, increase more and more the obstruction to the entrance of 
air, and finally death occurs from apnoea. The nursing infant usually ceases 
to nurse several hours before death, and a state of stupor commonly pre- 
cedes the fatal event, due to the accumulation of carbonic acid in the blood. 
In young infants, especially those under the age of six months, not only in 
bronchitis of the minute tubes, but in severe ordinary bronchitis, I have 
often observed toward the close of life intermission in the respiration. It 
occurs after every six or eight or ten respirations, and equals in duration the 



682 BRONCHITIS. 

time occupied in perhaps half a dozen respiratory movements. It is there- 
fore an unfavorable prognostic sign, but some in whom it occurs recover by 
active stimulation. 

The duration of acute bronchitis varies according to the extent of the 
inflammation. In the mildest form the patient is convalescent after three or 
four days, and in severe cases that terminate favorably the disease begins 
ordinarily to decline by the close of the first week or in the second. The 
progress of bronchitis is somewhat more rapid in young children than in 
those of a more advanced age. When convalescence is fully established it 
is not unusual for the cough to continue three or four weeks, though grad- 
ually declining. It is loose and painless, and is scarcely regarded by the 
patient. 

Death sometimes occurs as early as the second or third day in severe gen- 
eral bronchitis. The younger the infant, with the same extent and intensity 
of inflammation, of course the sooner the fatal result. The ordinary dura- 
tion of fatal bronchitis is from six to eight days. If the patient pass beyond 
the tenth day, decline of the inflammation may be confidently expected, with 
recovery, unless there be a complication. 

Occasionally bronchitis becomes chronic, lasting several months before 
it entirely ceases. The chronic form may result from mild as well as severe 
bronchitis. The acute fever and accelerated respiration which characterize 
the acute affection abate, and the general health is nearly or quite restored : 
but an occasional cough continues, and the respiration is often audible, from 
the mucus which collects in the tubes or from thickening of the mucous 
membrane. Sometimes there is moderate fever, especially in the latter part 
of the day. On auscultation coarse mucous, with perhaps sibilant and sono- 
rous, rales are observed in the chest. 

There is great liability in chronic bronchitis to exacerbations. The dis- 
ease often seems to be abating and there is prospect of its speedy cure, when 
all the symptoms are intensified. The exacerbations are due to the fact that 
the bronchial surface, when it has been a considerable time inflamed, is very 
sensitive to the impression of cold. Even when the disease is entirely 
relieved it is very liable to return by exposure to currents of air or changes 
of temperature. Chronic bronchitis occurs most frequently in the winter, 
spring, and autumn, when the weather is changeable, and is most intractable 
in these periods of the year. Many cases of chronic bronchitis are associated 
with dilation of the bronchial tubes or with emphysema. The general 
health in this form of bronchitis, when not dependent on a tubercular deposit, 
ordinarily remains good. Tubercular bronchitis, which is the result of a 
grave disease, is treated of in our remarks on Tuberculosis. It is attended 
with emaciation, and is obstinate on account of the nature of the primary 
aff"ection. It is due to the irritating efl'ect of tubercular matter lying against 
the bronchial tubes. 

Diagnosis. — Bronchitis can ordinarily be diagnosticated by the character 
of the respiration and cough. The absence of hoarseness, stridulous inspira- 
tion, and croupy cough excludes laryngitis, and the absence of the expiratory 
moan and of the stitch-like pain on coughing, which characterize pneumonia 
and pleurisy, excludes these diseases. Accurate diagnosis, however, can be 
most readily made by percussion and auscultation. Examination of the chest 
enables us to state with positiveness not only the nature, but the extent, of 
the afl"ection. If the inflammation be confined to the larger bronchial tubes, 
coarse rales are discovered in them, while finer mucous rales are absent. If 
the bronchitis be in the minute tubes, subcrepitant rales are discovered in 
them. Percussion gives clear resonance on both sides, except in those instances 
in which atelectasis or pneumonia has supervened. 



PROGNOSIS— TREATMENT. 683 

Prognosis. — Bronchitis limited to the larger bronchial tubes or to these 
and those of medium size terminates favorably in a large majority of cases. 
Occasionally, severe inflammation, not extending to the smaller tubes, proves 
fatal in young infants or those of feeble constitution. Bronchitis extending 
to the minute tubes is, on the other hand, a disease of great danger. It may 
be fatal at any period of childhood, but the younger and more feeble the 
patient the greater the liability to a fatal result. Under the age of one year 
it is one of the most fatal diseases of early life. 

The prognosis in the commencement of all cases of bronchitis of average 
severity in the young child should be guarded, on account of the tendency 
of the inflammation to extend, as has been already stated in the preceding 
pages. After five or six days extension ceases, and if during that time no 
increase in the severity of symptoms occurs, the prognosis is favorable. 
Signs which indicate an unfavorable result are increasing frequency of pulse 
and respiration, difficult and scanty expectoration, restlessness, a countenance 
expressive of suff'ering, and a progressively greater accumulation of mucus 
in the bronchial tubes, as determined by auscultation. Pallor and coldness 
of the face and extremities, lividity of the tips of the fingers, rapid and 
feeble pulse, drowsiness, diminution of cough, while the mucus and pus 
accumulate in the bronchial tubes, and, in young children, intermissions in 
the respiration, indicate the near approach of death. Cases may, however, 
recover by proper treatment, although the symptoms are most unfavorable. 

It is unnecessary to mention the favorable prognostic signs of bronchitis. 
This disease, when fully established, continues a certain number of days what- 
ever remedial measures are employed, and if the symptoms do not increase 
in severity during the first five or six days a favorable result is highly prob- 
able. The prognosis in chronic bronchitis is ordinarily favorable, so far as 
life is concerned, provided that no emaciation occur. If there be emaciation 
the bronchitis may be due to tubercles in the bronchial glands or lungs, and 
of course the prognosis is less favorable. 

Treatment. — Bronchitis may be rendered much milder, and perhaps 
prevented, by an emetic employed in the first twelve or twenty-four hours in 
conjunction with a warm bath. The physician is not, however, ordinarily 
called sufficiently early to render this treatment eff'ectual. 

Mild Bronchitis. — In mild bronchitis, the inflammation being limited to 
the larger tubes or to these and those of medium size, simple, soothing, 
expectorant, and laxative remedies are required. Mild counter-irritation may 
be produced by camphorated oil or a weak sinapism, and one of the following 
mixtures may be given. The late Dr. James Jackson of Boston, in his letters 
to a young physician, writes of the treatment : " For young children I employ 
the following : Take of either almond or olive oil, of syrup of squills, of any 
agreeable syrup, and of mucilage of gum acacia equal parts, and mix them. 
Of this mixture a teaspoonful may be given to a child two years of age ; 
a little less if younger and increased if older, so as to double the dose to one 
in the sixth year. This may be given from three to six times in the twenty- 
four hours. Sometimes a little opiate must be added at night to appease the 
urgent cough." Another good medicine is the mistura glycyrrhiza3 com- 
posita, half a teaspoonful of which should be given every two hours to a 
child of three years and one teaspoonful to one of six years. The syrupus 
ipecacuanhge compositus of the French Pharmacopoeia, the contre de la toux, 
consisting of ipecacuanha, senna, thyme, poppy, sulphate of magnesia, orange- 
flower water, wine, water, and sugar, being soothing and slightly laxative, is 
also a useful remedy. These cases also do well with simple mucilaginous 
drinks and confinement in a warm room. 

Bronchitis affecting* the Medium Size or Smallest Tubes. — The 



684 BRONCHITIS. 

use of leeches has been, for the most part, abandoned in the treatment of 
bronchitis, not only in infancy, but at all ages. The application of dry cups 
over the sternum is recommended by some judicious physicians as a proper 
remedy for bronchitis in infancy as well as childhood, and the use of the wet 
cup is even advocated for robust infants in the commencement of the inflam- 
mation ; but the beneficial effects derived from this treatment can be obtained 
by other measures which preserve the strength, and are therefore preferable. 

Local treatment applied to the chest in bronchitis is important, since, if 
properly made, it increases the comfort and obviously diminishes the intensity 
of the inflammation. Henoch, whose ample experience and sound judgment 
command attention, if not acceptance of his views, says of local treatment : 
" I strongly advise hydropathic applications to the chest from the neck to the 
umbilicus. A napkin or diaper is dipped in water at the temperature of the 
room, well wrung out, and then placed around the chest, without exercising 
any compression, so that the arms are free ; this is surrounded by a roll of 
batting and then covered by a layer of oil-silk or gutta-percha paper. When 
the fever is high these applications should be renewed at least every half 
hour ; later they may be kept for one or even two hours, and this continued 
for several days and nights. I have occasionally continued it for a week, the 
cool water being changed to a temperature of 26° to 27° R." 

The benefit derived from the cold-water application is, according to 
Henoch, threefold: First, the deep inspiration which the application of cold 
causes, thus expanding portions of the lungs which are liable to atelectasis ; 
secondly, " derivative irritation of the skin ;" and, thirdly, the production of 
moisture in the air surrounding the child, which he inhales. Deep inspira- 
tions are, in my opinion, caused to a greater extent by medicines which excite 
cough, as ammonia and warm applications certainly produce more derivation 
to the surface than cold. One benefit from the application of cold Henoch 
does not allude to, and that is the reduction of temperature. But I prefer 
for this purpose frequent sponging of the upper extremities and face with 
cold water, and perhaps its constant application to the head, I have observed 
marked relief from this use of cold water. 

For years, in my practice, the following external treatment has been 
employed with apparent benefit in nearly every case. For infants under the 
age of three months who have accelerated respiration and painful cough, 
indicating the need of external treatment, two poultices of ground flaxseed 
are prepared, covered by thin muslin, and made so moist that they wet the 
hand in holding them. They are made as thin as the pasteboard cover of a 
book, and of such a size that, applied in front and behind, they cover the 
entire chest. Camphorated oil is smeared over their under surface three or 
four times daily, and over their exterior oil-silk is applied. For infants over 
the age of six months I prefer poultices of the following: 

R- Pulv. sinapis, ,^j ; 

Pulv. seminis lini, ^^vj. 

The poultice, to give most relief, should be so wet as to cause constant moist- 
ure of the surface, and so irritating as to cause constant redness without 
necessitating its removal. Vesication should never be produced. Flannel 
wrung out of warm water made slightly irritating by mustard and covered 
by oil-silk also answers the purpose. External treatment should be employed 
in most instances so long as the respiration is hurried and cough painful. 
During the stage of convalescence, instead of the poultice, cotton wadding or 
batting around the chest increases the comfort and prevents taking cold. 
Derivation to the surface, early made and continued, tends to check the 



TREATMENT. . 685 

downward extension of bronchitis. Often improvement in the symptoms is 
observed, especially less dyspnoea and restlessness, immediately on the 
employment of the local measures recommended above. 

Internal Treatment. — Medicines are indicated which have a tendency to 
diminish the inflammation, to prevent its downward extension to the minute 
bronchial tubes, and to promote expectoration. The bowels should be kept 
open in all cases of bronchitis. For robust children at or over the age of 
six months the following prescription is useful in the commencement of the 
attack : 

R. Syr. ipecac, 

Spts. sether. nitr., da. ^ij ; 

01. ricini, ^iij ; 

Syr. bal. tolut., 5J. Misce. 

Dose: Half a teaspoonful to one teaspoonful, every second hour, for the age of one to 
two years. 

But the medicinal agent which experience has shown to be the most use- 
ful in the bronchitis of children is one of the salts of ammonium. In the 
treatment of infantile bronchitis depression must be avoided. The cough 
should be strong and frequent, for the chief danger occurs from the accumu- 
lation of viscid mucus in the minute tubes, so as to obstruct the entrance of 
air into the alveoli, leading to atelectasis and causing the dyspnoea which is 
so painful and prominent a symptom in this disease. Ammonii carbonas or 
chloridum better than any other agent promotes expectoration by exciting 
cough and rendering the mucus less viscid, and it does not reduce the strength. 
AVhen anxious parents ask me to prescribe something to relieve the cough, I 
reply that the more frequent the cough the better it is for the infant, since it 
affords the means of freeing the tubes from the accumulating mucus. For- 
merly I prescribed largely the carbonate, but Dr. Northrup, curator of the New 
York Foundling Asylum, has found evidences of gastritis in the stomachs 
of infants who have perished from various diseases for which the carbonate 
was administered. It should therefore be prescribed in a sufficient amount of 
mucilage or syrup or milk to prevent its irritating action on the stomach. I 
prefer to prescribe it in water, and direct it to be administered in milk. In 
feeble cases and cases attended by dyspnoea the carbonate is preferable to the 
chloride, since it is more stimulating, and it promotes the cough by slightly 
irritating the fauces. The ammonii chloridum may, in most instances, be 
given with benefit from the commencement, both in mild and severe bron- 
chitis, in infants under the age of one year, but in severe cases it is appar- 
ently less efficient than the carbonate. The following is a convenient formula 
for its employment : 

R. Ammonii chloridi, gj ; 

v^yr. bal. tolut., ^ij. Misce. 

Fifteen drops contain one grain, the dose at the age of three months. 
Five drops should be given at the age of one month, and thirty at the age of 
six months, in a little water. This expectorant should be given frequently, 
as every half hour or every hour in cases of severity. The urgent symptoms 
are relieved by free expectoration, which this medicine tends to produce. It 
should be given night and day. at the short intervals mentioned, until ameli- 
oration of symptoms occurs. The benefit from its use is most apparent under 
the age of eighteen months, or at the age when capillary bronchitis and 
atelectasis are most liable to occur. 

Medicines which exert a greater controlling effect on the action of the heart 
than those which we have mentioned are often required during the progress 



6S6 BRONCHITIS. 

of severe "bronchitis." If the patient give evidence of declining strength 
while the pulse is unusually rapid and the temperature elevated, quinine 
given in moderate doses, as two grains every fourth hour to a child of two 
years, has seemed to me useful as a heart tonic. It may be employed in the 
following formula : 

R. Quinise sulphatis, .^ss; 

Syr. yerbse santa? comp., ^ij. Misce. 

Give one teaspoonful every fourth hour. 

The tincture of digitalis in doses of one or two drops every second hour 
for infants between the ages of six months and two years is also useful 
as a heart tonic. In a case recently under treatment by Dr. Jacobi and 
myself the infant, aged twenty-three months, having a temperature varying 
from 1022° to lOSp, respiration 82 to 105, and pulse 165 and higher, took 
four drops of tincture of digitalis, besides the quinine and ammonii chloridum, 
three days, with apparently a good result from the digitalis. This remedy 
was afterward continued in two-drop doses, and the patient recovered. 

For robust children, with a strong and rapid pulse, with a temperature 
above 102°, the use of an antipyretic is indicated. Formerly, aconite or the 
more dangerous remedy, veratrum viride, was employed for this purpose ; 
but a better antipyretic for these cases is antipyrine, acetanilide, or phenace- 
tin. One grain of antipyrine, which is soluble in water, may be administered 
every third hour to an infant of one year. If the temperature fall to 102°, 
it should in ordinary cases be discontinued, since it is in a measure depress- 
ing. Its use is seldom required longer than two or three days. For fee- 
ble children, or those who have atelectasis or pneumonia complicating the 
bronchitis, quinine is preferable to either of the above antipyretics. 

When and how to employ opiates to procure the needed rest in the bron- 
chitis of children should be carefully considered. We have stated that a 
frequent and strong cough is required in the infant in order to prevent clog- 
ging of the minute tubes with muco-pus and to prevent atelectasis. Still, 
some respite from the cough, if it be frequent, is required to prevent exhaustion. 
I prefer for young infants to give the opiate separately from the expectorant, 
and only occasionally as they may need sleep. The following is a useful 
formula for an infant of six months if it be restless and without the proper 
amount of sleep : 

R. Liq. opii composit. (Squibb), gtt. x; 

Potass, broraidi, 3j ; 

Syr. riibi idsei (raspberry), ,^j ; 

Aquse, ^iss. Misce. 
Dose: One teaspoonful when needed. 

Eight drops of paregoric may be given in place of the above. Twice the 
dose of either of these opiates is sufficient at the age of twelve months. For 
older children Dover's powder — an eligible form of which is Squibb's liquid 
Dover's powder, the tinctura ipecacuanhse composita, one minim of which 
corresponds to one grain of the powder — is a useful remedy to procure sleep. 

During convalescence medicines should be administered less and less fre- 
quently or in smaller doses. Emetics in ordinary cases of bronchitis are not 
required, except in the commencement. In severe bronchitis, however, espe- 
cially when the smaller tubes are inflamed, they sometimes appear to be use- 
ful. The cases which may need their administration are those in which mucus 
and pus collect in the tubes more rapidly than they are expectorated, so as 



ATELECTASIS. 687 

to give rise to urgent dyspnoea. An emetic administered under such cir- 
cumstances may give prompt and decided relief. The object to be gained is 
obviously very different from that in the commencement of bronchitis, and 
such agents should be employed as act promptly with little depression. Ipe- 
cacuanha is probably the best emetic for this purpose. 

Infants oppressed by the accumulation of mucus and pus may sometimes 
be relieved by tickling the fauces with the finger. This provokes vomiting, 
and the viscid mucus which collects at the entrance of the glottis is removed 
by the finger. 

The diet should, as a rule, be nutritious through the entire disease ; but 
robust patients or those who have ordinary health, if over the age of two 
years and affected with primary bronchitis, are sufficiently nourished by light 
diet, chiefly farinaceous, in the first days of the attack, after which animal 
broths are proper. Whatever food is given in severe bronchitis must be in 
the form of drinks, since the appetite is lost and solid food is not taken, 
while the thirst is such that liquids are less likely to be refused. 

In primary bronchitis, if mild or of ordinary severity, alcoholic stimu- 
lants are not required. In secondary bronchitis they are often needed, and 
also in severe primary bronchitis if there be dyspnoea with evidences of 
prostration. In the infant two drops of brandy for each month in the age, 
given every hour or second hour, enable the child to expectorate with more 
freedom and less exhaustion. 



CHAPTER YI. 

ATELECTASIS. 

In certain new-born infants the lungs do not undergo inflation or only a 
portion of the lobules is inflated — to wit, those in the upper lobes — while the 
remainder of the organ continues unchanged from the foetal state. This non- 
inflation of the lung is designated congenital atelectasis. It is apparently 
not due, unless in rare instances, to defective formation of the respiratory 
apparatus, for at the autopsies of cases which have ended fatally, as most 
cases do at an early period, insufilation is easy, there being no occlusion of 
the air-passages nor unusual adhesion of the walls of the alveoli to prevent 
the admission of air. Physicians have believed that in some instances they 
discovered the cause in an enlarged thymus gland, which compressed the 
lower part of the trachea, but this cause has not seemed to exist or was 
exceptional in cases which I have observed; for although the thymus at 
birth is large, having nearly the size of an unexpanded lung, it has not 
seemed to me to be unduly enlarged in most atelectatic cases which I have 
examined after death. 

The ordinary proximate cause of atelectasis neonatorum is feebleness of 
inspiration, whether due to general debility, as in infants born prematurely, 
or weakened by placental hemorrhage in the last months of foetal life, or, as 
is frequently the case, to injury of the brain and consequent impairment of 
the function of the pneumogastrics during birth. I have more fully treated 
of this form of atelectasis in the chapters which relate to the maladies inci- 
dental to the birth of the child, and to these the reader is referred. 

Acquired atelectasis, or collapse of lung, is less extensive than con- 
genital atelectasis, being confined to a portion of a lobe and often to only a 



688 ATELECTASIS. 

few lobules. It occurs chiefly during the period of infancy and in feeble 
children. It is a common malady in foundling asylums in wasted infants 
who perish before the close of the first year. I have frequently at the 
autopsies of such infants observed it along the thin inferior margins of the 
lower lobes and in the tongue-like prolongation of the left upper lobe. In 
this class of cases catarrh of the bronchial tubes appears to have little or no 
agency in causing the collapse. The cause is found in the impaired functional 
activity of the lungs. In the state of debility the heart beats feebly and 
the stream of blood from it to the lungs is small and slow, so that the inspira- 
tion of a small amount of air suffices for its decarbonization. The inspira- 
tions also are seen to be feeble, causing little expansion of .the walls of the 
thorax. Consequently, the entire lung is imperfectly inflated, as is seen in 
fatal cases, but the distant thin portions of the organ are least expanded. 
These, receiving little or no air, soon begin to contract from the presence of 
the elastic tissue, and collapse or atelectasis ensues. 

This has been the most common form of atelectasis in cases of this malady 
which I have observed in foundling asylums, and it probably occurred in the 
manner which I have described. 

Another cause of acquired atelectasis to which all writers allude is bron- 
chial catarrh, which, commencing in the larger tubes, extends downward into 
those of smallest size. By the swelling of the mucous membrane and the 
accumulation of viscid muco-pus, which cannot be expectorated, certain of 
these tubules become occluded, so that the inspired air is shut off from the 
alveoli situated beyond them. Occlusions are obviously most likely to occur 
in the bronchitis of feeble infants whose cough has little expulsive force, 
so that debility is also a factor in the production of this form of atelectasis. 
The portion of lung withdrawn from the respiratory function soon collapses, 
the air which it contained being probably in part expired, but chiefly absorbed. 

Atelectasis is not, however, so important or frequent a complication of 
bronchitis as was formerly supposed, for catarrhal pneumonitis due to exten- 
sion of the inflammation from the bronchioles into the lung has been mistaken 
for it. Solid non-crepitant nodules or portions of lung are frequently observed 
at the autopsies of infants who have perished of severe bronchitis, and these 
may be atelectatic or pneumonic, but they are more frequently the latter than 
was formerly supposed. 

The possibility of insufflating these solid portions when removed from the 
body after death was till within a few years regarded as decisive proof of 
atelectasis. It is now known that this is not a reliable test, since a lung 
solidified by recent catarrhal pneumonitis can be almost as readily inflated as 
one which is collapsed ; but the inflated pneumonic lung is more solid and 
resisting when pressed between the thumb and fingers than is the collapsed 
lung. The decisive proof is aff"orded by the microscope, by which cell-pro- 
liferation is discovered within the alveoli in catarrhal pneumonitis, while it is 
lacking in simple collapse. An increase of the dyspnoea not infrequently 
occurs in severe infantile bronchitis, without either pneumonia or collapse 
from the accumulation in the bronchioles of the secretion which is with 
difficulty expectorated, but if dulness on percussion and other physical signs 
indicate solidification of the lung at some point, of course pneumonia or col- 
lapse has occurred. If a sufficient amount of lung be involved to produce 
well-marked physical signs, the disease is in most instances pneumonia and 
not collapse, though it may be the latter. Both these pathological states 
may, however, occur in the same lung as complications of severe bronchitis. 
The severe paroxysmal cough of pertussis, especially when accompanied by 
considerable secretion, frequently produces collapse of portions of the lower 
lobes, while it causes emphysema in the upper lobes. 



SYMPTOMS— ANATOMICAL CHARACTERS 689 

SYxMPTOMS. — Atelectasis resulting from bronchitis gives rise to no new 
symptoms. So far as it has any appreciable effect, it aggravates certain 
symptoms of the primary disease, but as it is ordinarily limited to a small 
area, this effect is not very marked. AYhen a bronchial tube is so occluded 
by muco-pus that the alveoli with which it cornmunicates collapse, there is 
ordinarily at the same time more or less accumulation of this secretion in 
other tubes throughout the lungs. Therefore, the entrance of air into the 
alveoli with which these tubes communicate is slow and difficult, but usually 
without complete obstruction and without true atelectasis, but with a semi- 
collapse such as we observe in fatal croup. This explains the dyspnoea which 
is present in these cases. If the secretion be expectorated from these tubes, 
the dyspnoea abates, even if the plug which has completely occluded a tube 
and the consequent atelectasis remain. 

Atelectasis occurring in wasted and feeble infants in consequence of the 
diminished force of the inspirations does not in most instances give rise to 
any prominent symptom, since it occurs chiefly in distant thin portions of 
the lungs. I have observed an occasional short, nearly painless, cough in 
such infants when the autopsy revealed no pulmonary lesion except the 
atelectasis. 

Anatomical Characters. — The portion of lung which is affected with 
recent atelectasis has a dark-brown or dark-bluish color. It is depressed 
below the general level of the lung, is firm and non-crepitant on pressure, 
and its incised surface is smooth. Hypersemia supervenes, for a portion of 
lung in which the circulation continues, but from which air is excluded, becomes 
congested. In acquired atelectasis the congestion is especially marked, since 
the vessels which have been adapted by growth for a larger area are com- 
pressed into one of smaller extent, so that they become tortuous and bulging 
within the luniina of the alveoli, while the free flow of blood through them 
is retarded by the constriction of the elastic fibres of the lung. An obvious 
and certain result of the hypergemia is the transudation of serum into the 
alveoli, producing oedema. This union of pulmonary hypersemia with 
oedema, by which air is excluded from the alveoli, constitutes the state 
known to pathologists as splenization, and in proportion as it occurs the 
lung depressed by the atelectasis rises toward the general level. It may 
even rise above it, and it now has a doughy, elastic feel. The pathology 
of these oedematous atelectatic spots, heretofore obscure, has been clearly 
explained by Rindfleisch. 

If the patient live and the atelectatic lobules do not soon return to a 
state of health, they undergo further changes. Rindfleisch says : " From the 
series " (of changes, provided inflammation do not occur) " we especially ren- 
der prominent two conditions — inveterate oedema and slaty induration. But 
inflammation does commonly occur after a time in a collapsed lung." Those 
who are familiar with the post-mortem examination of infants will fully 
agree with Rindfleisch when he says : '• Splenization, quite generally taken, 
appears to present extraordinarily favorable preliminary conditions for the 
occurrence of inflammatory changes. It may directly represent the initial 
hyperaemia of acute inflammation, and be followed by lobular and lobar, but 
constantly catarrhal, infiltrates." It is well known by pathologists that pro- 
tracted congestion, active or passive, of whatever organ or tissue, is very 
liable to pass from a state of simple stasis of blood to one of cell-prolifera- 
tion, and the atelectatic lung, as I have myself observed at autopsies, affords 
a common example of this. I have several times made or have procured 
microscopic examinations of the atelectatic portions of lungs of infants 
who had died for the most part in a wasted and enfeebled state, and have 
found in them clear evidence of the presence of a catarrhal pneumonia. 

4t 



690 PNEUMONIA. 

The interesting fact therefore must be recognized that atelectasis fre- 
quently passes to a state of inflammation, so as to present the characters 
of ordinary hypostatic pneumonia, and no doubt undergo the same subse- 
quent changes. 

Atelectasis when recent and simple or uncomplicated may soon disappear 
by the expectoration of the obstructing secretion, if such be present, or if 
there be no obstruction by increased force of inspiration. If it do not soon 
disappear it undergoes one of the ulterior changes alluded to above, and 
henceforth the symptoms and history are those of the new malady which has 
supervened. 

Treatment. — The treatment of acquired atelectasis is simple. If it be 
recent and there be evidence that it is due to the accumulation of the secre- 
tion in the bronchial tubes, an emetic which acts promptly and with the 
least possible depression may be very useful. It is especially indicated if 
there be little or no pneumonia, the strength not greatly reduced, and there 
be dyspnoea with insufficient decarbonization of blood in consequence of the 
abundance of the secretion in the smaller tubes. An emetic which acts 
promptly and with little prostration ma}'- aid greatly in establishing the res- 
piratory function in collapsed lobules by expelling the obstruction and pro- 
ducing a freer and deeper inspiration. One of the best if not the best 
emetic for this purpose is sulphate of copper, given in a dose of one or two 
grains to a child of one year. With or without the use of the emetic, our 
main reliance must be on sustaining and stimulating measures, by which the 
cough, the cry, and the inspirations acquire more volume and force. Most 
cases require alcoholic stimulants and the ammonium carbonate. Rube- 
facient applications to the chest are also commonly employed, and are 
probably useful. 



CHAPTER VII. 

PNEUMONIA. 

Catarrhal Pneumonia. 

This is the common form of pneumonia under the age of three years. 
In most cases it results from bronchitis by extension of the inflammation. 
Hence it is designated by the terms broncho-pneumonia and lobular pneu- 
monia. 

Etiology. — Catarrhal pneumonia, as we have stated above, commonly 
results from simple bronchitis. The inflammation, affecting first the larger 
bronchial tubes, extends to the bronchioles, and from them to the air-cells 
in certain lobules. Its causes under such circumstances are evidently the 
same as those of the bronchitis which precedes and accompanies it. It often 
occurs as a complication of certain infectious maladies, among which we may 
mention pertussis, measles, diphtheritic croup, influenza, and, more rarely, 
scarlatina, variola, typhoid fever, and erysipelas. Ill-nourished, rachitic, and 
anaemic children with little power of resistance are most liable to it. It is 
in the cities especially common among the children of the tenement-houses, 
who live in small, overcrowded, overheated, and dirty apartments, and are 
frequently taken from these apartments to the lower temperature of the 
streets or are exposed at open windows. Different opinions have been 



CATARRHAL PSEUMOSIA. 691 

expressed as to the mode in which pneumonia supervenes upon capillary 
bronchitis. The theory of direct propagation of inflammation from the 
minute bronchial tubes to the air-cells is plausible, but Buhl holds that the 
alveoli become inflamed by the entrance into them from the bronchioles, 
during inspiration, of inflammatory products, which act as an irritant. A 
form of subacute catarrhal pneumonia sometimes results from hypostasis 
or passive congestion. It is not uncommon in infant asylums in infants 
enfeebled by chronic disease, who have weak action of the heart and languid 
circulation. Lying in their cribs day after day, with little movement of the 
body, they are very liable to passive congestion of depending portions of 
their lungs, and this by and by eventuates in a pneumonia presenting some 
peculiarities, but of the catarrhal form. It is sometimes designated hypo- 
static pneumonia. It is so frequent in foundling asylums, where feeble 
infants are received and treated, that certain physicians, whose observations 
have been largely in such institutions, have almost ignored any other form 
of pneumonia in infants. Billard, a close and accurate observer, wrote 
nearly half a century ago : '• Pneumonia of infancy presents peculiar cha- 
racters, in which it differs from the same aff'ection in adults. Instead of 
being an idiopathic aff'ection arising from irritation developed in the pulmo- 
nary tissue under the influence of atmospheric causes, which often excite the 
disease, the pneumonia of young infants is evidently the result of a stagna- 
tion of blood in their lungs. Under these circumstances this blood may 

be regarded as a kind of foreign body It would therefore appear 

that inflammation of the lungs, which produces hepatization, arises in infants, 
in general, from some mechanical or physical cause." A^alleix also states 
that he found the lesions of pneumonia in a majority of the infants who died 
in the Hopital des Enfants Trouves. The statements of Yalleix are applica- 
ble also to the Infants' Hospital, the Foundling Asylum, and the Nursery and 
Child's Hospital of this city, as regards those cases in which death results 
from chronic disease. We shall see hereafter that hypostatic pneumonia is 
also a common complication of chronic infantile entero-colitis, the summer 
complaint of the cities. 

Catarrhal pneumonia of infants sometimes results from atelectasis or col- 
lapse. It is not unusual to find, at the autopsies of infants who have died 
in a state of emaciation and feebleness, portions of the lungs remote from 
the bronchi collapsed, as, for example, the thin edges of the inferior lobes and 
the tongue-like process of the upper lobe, the process which lies over the 
heart. The immediate cause of the collapse has been a bronchitis, or it has 
resulted directly from the general weakness of the infant and its feeble 
respirations. Now, a collapsed lung soon becomes the seat of passive con- 
gestion. The functional activity of an organ favors circulation through it, 
and if the function be abolished the flow of blood in the part is retarded and 
stasis more or less complete results. The hyperasmic state of collapsed 
pulmonary lobules presents the same anatomical condition for the super- 
vention of pneumonia as occurs in cases of hypostatic congestion. Conse- 
quently, cell-proliferation soon begins in the collapsed alveoli, the volume 
of the aff"ected lung increases and it becomes firmer and more resisting to 
the touch, and the microscope reveals the characters of a subacute but gen- 
uine catarrhal pneumonitis. I have made or have procured microscopic 
examinations of a considerable number of such specimens, and have found 
the alveoli more or less filled with cells of the epithelial character. (See 
article Atelectasis). Pneumonia resulting from hypostatic congestion and 
that occurring from atelectasis are not only subacute, but usually protracted. 

Anatomical Characters. — If we have an opporttmity to make a post- 
mortem inspection of the inflamed lung when broncho-pneumonia has con- 



692 



PNEUMONIA. 



tiiiued a few days we will find the pleura covering it either normal or covered 
in spots with a thin film of fibrin. The bronchial tubes contain muco-pus, 
and their walls are thickened and congested. The inflamed lobules are few 
or many, and they are more numerous in the lower lobes and in its posterior 
portion than elsewhere. Their incised surface is UQt granular, as in croupous 
pneumonia, but smooth, and its color in recent cases is a pale red or deep red. 
In protracted cases the color may be grayish, but the change from red to gray 



or croupous pneumonia, so 



hepatization does not occur as early as in lobar 

that weeks after the commencement of inflammation in the lobule its color 
may be red. White points or lines in the lobule indicate the location of the 
bronchioles. The inflamed lobule is in some cases very distinct from the 
surrounding healthy parenchyma, but in other instances it gradually blends 
with it. 

In some cases the air-vesicles contain chiefly pus, in others chiefly epithe- 
lial cells or epithelial cells and pus, and in others still epithelium, pus, and 
fibrin. Mixed with these inflammatory products we detect also red blood- 
corpuscles. The capillaries in the walls of the vesicles are large and sinuous. 
The amount of inflammatory products in the alveoli varies greatly in diff"erent 
cases. The alveoli may be only partially filled, or they may be so packed 
that it is difiicult to detect the alveolar walls. The adjacent non-hepatized 
lobules do not exhibit any marked change, except that their epithelial cells 
may be somewhat swollen and more distinct than in health. The bronchial 
tubes not only contain more or less muco-pus and epithelial cells, but their 
walls are frequently thickened and infiltrated with pus-cells and connective- 
tissue cells. This infiltration causes the bronchioles to appear as white lines 
or dots in the inflamed area. 

In protracted cases the red color changes to gray, this change commencing 
in the interior of the lobules and extending outward. In gray hepatization 



Fig. 42. 




Fig. 42 represents an inflamc'<l air-voicU' ivon\ tlie luns f>f a cliikl who died of catarrhal 
pneumonia sii])ervL'ning on pertussis. 

the epithelial and pus-cells have undergone granulo-fatty degeneration. If 
resolution do not occur and the disease reach a still more advanced stage, the 
granulo-fatty degeneration becomes more complete, and the lobules enter the 
stage of cheesy degeneration, becoming yellowish-white and hard and homo- 
geneous, the elements which make up the lobules being no longer discernible. 
The ulterior chanoe in the gravest cases is softening and the formation of 



CROUPOUS PNEUMONIA. :693 

cavities, or interstitial pneumonia may supervene, with an increase of the 
connective tissue. Cheesy degeneration and interstitial pneumonia are much 
more frequent in lobular pneumonia, the disease which we are describing, 
than in lobar or croupous pneumonia, and when the stage of cheesy degen- 

FiG. 43. 



Fig. 43 represents lobular pneumonia of a more severe grade, some fibrin being present in the 
centre of the air-vesicle. Both plates are copied from Delatield's Pathological Anatomy. 

eration is reached the conditions are present in which tuberculosis is likel}^ to 
supervene. 

In a large proportion of instances, when broncho-pneumonia has not con- 
tinued longer than two or three weeks, the inflamed lobules can be inflated 
after death. We would infer that this would be possible in cases in which 
the alveoli are only partially filled with the cellular elements. It was for- 
merly supposed that if an infant died, having had the dyspnoea and other 
symptoms characteristic of severe bronchitis or broncho-pneumonia, and por- 
tions of the lungs were found firm and without air, if they could be inflated 
the pathological state was atelectasis; if they could not be inflated, it was 
pneumonia. But I have many times been able to inflate lobules that were 
undoubtedly inflamed, though when inflated they were still semi-solid on 
palpation, so that the fact of insufflation or non-insufflation is not a test of 
the presence of atelectasis or pneumonia. Still, as we have elsewhere stated, 
a lung primarily collapsed is very liable to take on a low grade of pneumonia. 

Croupous Pneumonia, 

also designated fibrinous pneumonia and lobar pneumonia, is the common 
form of pneumonia in the adult, audit is not infrequent in children over the 
age of five years. It rarely occurs under the age of three years, but cases 
have been reported. It involves an entire lobe or a large part of a lobe. 
Besides the parenchyma, the smaller bronchial tubes also participate in the 



694 PNEUMONIA. 

inflammation. Croupous pneumonia is usually a primary disease, but it is 
occasionally secondary, as, for example, when it occurs in certain debilitating 
diseases, as nephritis, or in infectious diseases, as occasionally in measles and 
pertussis. 

Etiology. — Formerly croupous pneumonia was commonly attributed to 
catching cold, but the microscopic examinations and experiments of Klebs, 
Friedlilnder, and Frankel have shown that this disease is microbic, and the 
two latter gentlemen, it is believed, have detected the microbe which causes 
the inflammation in ordinary cases, and they have given it the name pneumo- 
coccus. It has a breadth of about one-third its length, and it occurs in 
groups of two or more surrounded by a gelatinous envelope. According to 
the observations of Salvioli, Eberth, and Nauwerk, it appears that the 
pneumococci may also enter the general circulation, and, being conveyed to 
distant organs, may excite inflammation in them : as, for example, nephritis, 
meningitis, and pericarditis. In ordinary cases of croupous pneumonia it is 
probable that the pneumococcus has entered the lungs by inspiration of 
infected air, and certain observers believe that it sometimes enters the 
blood and produces disease elsewhere, while the lungs escape. Croupous 
pneumonia is more common in certain years and certain seasons than in 
others. Its frequency in the spring months has been mentioned by physi- 
cians in difl"erent countries. It was common among children, according to my 
observations, in April, 1890, in New York City, after a mild and very rainy 
winter, the disease commencing suddenly with considerable elevation of tem- 
perature, and the physical signs of pneumonia being sufficient for diagnosis 
on the second, third, or fourth day. Epidemics of croupous pneumonia some- 
times occur in certain localities, lasting weeks or months, and there are 
also certain infected houses in which new cases of this inflammation occur 
during many months. In the Amberg prison in 1880, 161 cases of pneu- 
monia were treated, and in the ceiling of the dormitory in which most of the 
cases occurred Keller detected pneumococci, cultivated them, and success- 
fully inoculated animals with them. Bad ventilation, overcrowding, and 
uncleanliness favor the occurrence of pneumonia, and epidemics have ceased 
when troops were removed from crowded and infected barracks to those that 
were more spacious and cleaner. 

It is the opinion of some good observers that other microbes besides the 
pneumococcus may cause croupous pneumonia — that when this form of pneu- 
monia occurs in the common infectious diseases, as scarlet fever, pertussis, 
and measles, the specific microbes of these diseases enter the alveoli and 
excite the inflammation. Prof. Prudden, who has given much attention to 
the pathology of pneumonia, expresses the opinion that while the pneumo- 
coccus ordinarily causes croupous pneumonia, it may result from other 
microbes, especially when it occurs as a complication of the common microbic 
or infectious diseases. It is a question also whether it does not sometimes 
occur without the agency of microbes — especially from taking cold, in accord- 
ance with the popular belief — and in those rare cases in which it results 
from severe injuries it seems probable that the microbe is not the causal 
agent. 

Anatomical Characters. — Croupous or lobar pneumonia aff'ects an 
entire lobe or even an entire lung. Its first stage is that of congestion, which 
is characterized by distension of the arterioles and an increased afflux of blood 
to the part. In the second stage, or that of red hepatization, the lung becomes 
more solid and resisting on palpation, and at the same time it breaks down 
easily on pressure. Its color is a deep red, and its section presents the 
appearance of granules closely aggregated. Each granule is the contents of 
an air-cell. The bronchial tubes connectino- with the inflamed lobule contain 



CR UPO US PXE UMONIA. 



695 



muco-pus, fibrin, and epithelium, and tlie pleura covering the inflamed lobe is 
coated with fibrin. 

The substance which fills the air-vesicles and gives the torn or incised 
surface of the inflamed lobe its granular appearance consists of epithelial 
cells, pus-cells, red blood-globules, and fibrin. The blood-vessels are dis- 
tended with non-coagulated blood. The fibrin usually occurs in a network. 
The epithelial cells are abundant, and they are frequently enlarged and 
granular. The pus-cells are abundant ; the red corpuscles are few, or 
they may be so abundant that they fill some of the air-vesicles. ^Yhen the 
second stage, or that of red hepatization, is completed, the air-vesicles are 
entirely tilled with the inflammatory products, so that in the cadaver they 
cannot be inflated. The third stage, or that of gray hepatization, gradually 

Fig. 44. 




Fig. -44. copied from Delafield's Pathol on j raj Aiiafumij. repre-L-iit^ an air-vehicle from the lung of a 
patient who died forty-eight hunrs after the cuinnieneement et croU]Juus pneumonia. The 
vesicle is only partially tilled with inflammatory products, on account of the brief duration 
of the inflammation. 



supervenes after a few days upon the stage of red hepatization, a gray mottling 
first occurring ; subsequently the gray color becomes complete. In this stage 
the same elements reluain. but the congestion diminishes, the red corpuscles 
lose their color, and the inflammatory products gradually undergo granular 
degeneration. When they are filled with granules the red color is entirely 
replaced by the gray. Dr. Delafield states that the inflamed lung was found 
in this state in one-fourth of the cases examined by him. Death occurred in 
these cases between the fourth and twenty-fifth days. The stage of resolu- 
tion succeeds in favorable cases, in which the inflammatory products soften, 
liquefy, and are absorbed or expectorated. The hepatized lung, instead of 
resolving, may undergo a change identical with or closely resembling cheesy 
degeneration. It becomes dry and firm and of a white cheesy color. Epi- 
thelium, pus, and fibrin can be detected in some of the alveoli, while in others 
they are replaced by a granular mass. Again, in severe cases portions of the 
lung may undergo necrosis in consequence of arrest of circulation. Delafield 



696 PNEUMONIA. 

lias observed in these cases the presence of a large amount of fibrin, and but 
little pus and epithelium. At a later stage the cavities formed contained pus. 
This is a serious state, which is likely to eventuate in cheesy degeneration of 
the bronchial glands and tuberculosis. 

Septic or Embolismal Pneumonia. 

In rare instances in infancy and childhood pneumonia results, as it more 
frequently does in the adult, from an embolus detached from a clot which had 
formed in some remote vein, in consequence of arrest of circulation in it, by 
inflammation of the contiguous tissues. This is described by writers as a dis- 
tinct form of pneumonia, designated embolic or embolismal. A specimen 
showing this mode of causation was exhibited by me at the New York Patho- 
logical Society in February, 1868. An infant, born January 22, 1868. of 
strumous parents had been fretful, but without appreciable ailment till Feb- 
ruary 3d, when inflammation of the connective tissue occurred on the anterior 

aspect of the left leg, a little below the knee. 
Fig. 45. This extended downward, suppurated, and 

the pus was evacuated February 5th. In 
the mean time three other similar inflamma- 




„^^. tions occurred — two on the right foot and 

%W''M\'^^ SS^>v> leg, and the other over the parietes of the 

% %^ *'4?/ \&^ ^>^\ c^^st in the right inframammary region. 

1% cli^Sl^Hi tv^^f^iy- Suppuration occurred in all of these. 

"^^i'^? "l>^ ^\ ^3^81 C)n February 8th this infant was suddenly 

' «% t* S^'i^i^^ V^ , "^0^^ seized with extreme dyspnoea, and died in a 

"^^^li^^S^^/' " '%^' \ few hours. Numerous minute puriform col- 

"^ft '''i^lSfeii te> "'^, V. ^- . lections (formerly called metastatic abscesses) 

'^'^^r^:^^^ i^f --'o. • were discovered in each lung, most of them 

scarcely larger than a pin's head. One of 

them, on the right side in the middle lobe, connecting with a bronchial tube, 

had ruptured into the pleural cavity, causing pneumothorax, collapse, and 

incipient pleuritis. 

The annexed figure exhibits the microscopic appearance of this softened 
fibrin, which to the naked eye so closely resembled pus. 

On account of the speedy death the emboli had produced in the lobules 
where they had lodged little more than congestion or the first stage of pneu- 
monia around them. Had the infant lived longer, doubtless the microbes 
and ptomaines would have caused a greater amount and more advanced stage 
of pneumonia. 

Cheesy Pneumonia. 

Cheesy degeneration of the inflammatory product occasionally occurs in 
the croupous form of inflammation, but it is more common in the catarrhal. 
I have most frequently observed it in New York during epidemics of measles, 
when this form of pneumonia supervened upon the catarrhal bronchitis of 
that disease. Cheesy pneumonia is in its nature chronic and attended with 
great reduction of the vital powers. 

Cheesy degeneration of the exudate consists essentially in the absorption 
of the liquid portion and fatty degeneration of the solid. The obstruction 
of the circulation in the capillaries and the accumulation of cells in the 
alveoli and bronchioles which cannot be expectorated are conditions which 
favor cheesy metamorphosis. The appearance and consistence of the lung 
when it has undergone this change are well expressed by the term which is 



CHEESY PNEUMONIA. 697 

employed to designate it. The cheesy mass consists of fatty, shrivelled, and 
fragmentary cells, and amorphous matter in which can be traced the fibres 
of connective tissue and larger vessels of the parenchyma, the other histo- 
logical elements having disappeared. 

The caseous mass after a time softens, attracting moisture from the sur- 
rounding tissues. The molecular detritus and the shrivelled cells are now 
suspended in a liquid, and, like any dead matter, they are irritant to the sur- 
rounding lung-substance. The bronchial tube which supplies the affected 
lobule, and which in many instances was the starting-point of the disease, 
again becomes pervious, either by softening of the plug or by ulceration at 
a higher point upon its walls, and air is admitted, which promotes the putre- 
factive process and chemical changes of the caseous substance. 

The presence of softening caseous matter in the lungs very frequently 
leads to the development of tubercles (see art. Tuberculosis), and accordingly 
before the case ends clusters of tubercles may appear in the connective tissue 
and walls of the vessels of the lungs and in other organs. 

In the subsequent progress of cheesy pneumonia, if the patient live 
sufficiently long, more or less expectoration of the offending substance occurs, 
producing a cavity. Around the cavity a vascular pyogenic membrane forms, 
upon which granulations arise. These granulations, which produce pus abun- 
dantly, and from which small extravasations of blood are frequent, are grad- 
ually transformed into connective tissue. If the dead portion be expectorated 
and there be a single small cavity, the child may recover, the empty space 
being finally filled up by the extension of the granulations and the production 
of a cicatrix, which contracts, producing a puckered appearance. Ordinarily, 
however, there are several centres of caseous degeneration, and several cav- 
ities resulting, which continue to enlarge by the progressive softening of 
the cheesy matter. Often, also, the cavities intercommunicate. The bron- 
chial glands undergo hyperplasia, and certain of them are liable also to 
become cheesy. As the disease advances the suppuration and expectoration 
increase. The fatal result occurs sooner in children than in adults, and there- 
fore the destructive and inflammatory lesions observed at autopsies are ordi- 
narily not so far advanced in the former as in the latter. Other unfavorable 
changes may occur in the hepatized lung, but cheesy degeneration is the most 
common and noteworthy. 

To the possibility of inflating a lung which presents to the naked eye the 
appearance of pneumonia we have alluded in a foregoing page. The facts 
as regards the possibility of insufflation are these : In croupous pneumonia, 
when it has passed beyond the first stage, insufflation is impossible in the 
lung of the child as well as adult with the utmost force of the breath. We 
produce emphysema in healthy portions of the lungs, while the inflamed area 
is not encroached upon. 

On the other hand, in catarrhal pneumonia, which we have seen is the 
common form of pulmonary inflammation in children under the age of three 
years, and in which less distension of the air-cells by inflammator}^ products 
occurs, the lung can be inflated, except in protracted cases, but when fully 
inflated the solidified lobules can still be felt between the thumb and fingers. 
In protracted catarrhal pneumonia, as well as in protracted collapse — which, 
indeed, may and often does become a pneumonia — full inflation is impossible. 
Central portions still remain impervious to air. While, therefore, the possi- 
bility or impossibility of inflating a lung removed from an adult, and which 
presents to the naked eye the appearance of pneumonic solidification, is a 
valuable sign as indicating whether or not the disease be pneumonia, this 
test is uncertain and unreliable when applied to the pulmonary lesions of 
children under the age of three years. 



698 PNEUMONIA. 

Symptoms. — Croupous pneumonia commonly begins abruptly or it is pre- 
ceded for a brief period by symptoms of a cold. In the adult the abrupt 
commencement is ordinarily with a chill. In the child there is often a sensa- 
tion of chilliness, but a distinct chill is not common. Convulsions sometimes 
occur in place of a chill. Catarrhal pneumonia, being ordmarily consecutive 
to bronchitis, begins in a more gradual way, its sytnptoms being preceded by 
and associated with those of the primary affection. 

The symptoms of acute pneumonia, whether catarrhal or croupous, are 
the following : Anorexia, thirst, restlessness, elevation of temperature, accel- 
eration of pulse according to the intensity of the inflammation and the fee- 
bleness of the patient, flushed face, a countenance expressive of suffering, 
accelerated respiration, with an expiratory moan. These symptoms are con- 
stant in the acute inflammation unless of the mildest form. Those which 
are important I shall explain more fully. 

The expiratory moan is described by writers as a pathognomonic symp- 
tom of pneumonia or of pleurisy. It is due to the pain experienced from 
the movement of the inflamed part. As a rule, the expiratory moan indi- 
cates either pneumonia or simple pleuritis ; but there are exceptions. It 
may occur, for example, from indigestible substances in the stomach and 
intestines, giving rise to acute dyspepsia, or from certain forms of abdominal 
inflammation which render movements of the diaphragm painful, as dia- 
phragmatic peritonitis. 

The cough in the first days of pneumonia is usually dry or hacking and 
painful. It afterward, if the case be favorable, becomes looser and is pain- 
less. We very seldom observe in the child the bloody sputum which cha- 
racterizes pneumonia in the adult, since in catarrhal inflammation there is 
much less exudation of blood-corpuscles. The sputum, which in this form 
of the disease is the product of secretion and cell-proliferation, is at first thin 
and frothy, but afterward thicker and less tenacious from the increased num- 
ber of cells. There is often, in the first period of the inflammation, pretty 
severe and constant headache, the patient complaining of the head, if old 
enough to speak, before he does of the chest. In a severe attack the child 
at this period lies with the eyes shut, apparently in a half-conscious state, 
fretful if spoken to or aroused, so that the physician may be led to suspect 
the presence of cerebral disease. If there be vomiting accompanied with 
sudden twitching of the muscles and convulsions — symptoms which some- 
times occur — the liability to error in diagnosis is greatly increased. Cerebral 
symptoms are more prominent in the commencement of pneumonia than sub- 
sequently. As the disease advances they subside, and symptoms referable to 
the chest become more conspicuous. 

The breathing is, as I have said, accelerated. Thirty or forty respirations 
per minute are common, and in severe cases the number reaches sixty or even 
eighty. In infants there is greater frequency of respiration than in children. 
In those at the breast, if the dyspnoea be urgent, nutrition is sometimes seri- 
ously interfered with, since in these severe cases respiration is performed 
more through the mouth than nostrils, so that if the infant seize the nipple 
it is forced to relinquish it in order to breathe, dilation of the alae nasi 
and depression of the inframammary region accompanying inspiration. The 
dyspnoea in catarrhal pneumonia is often due in great part to accompanying 
bronchitis. 

The temperature in mild cases of pneumonia is elevated to about 101° to 
103° ; in severe cases it may reach 105° or even 107°, the former being the 
highest observed by Mr. Squire. In 97 observations made by M. Roger the 
average temperature was 104° during the active period of the inflammation. 
The face is therefore flushed and the heat of surface pungent, except in 



CHEESY PNEUMONIA. 699 

weakly children, in whom, even in severe and active inflammation, the face 
is sometimes pallid and the extremities of natural or less than natural 
temperature. 

The tongue is moist and covered with a light fur ; the thirst is such that 
nutriment may be given in the form of drinks when the loss of appetite pre- 
vents the use of solid food. The bowels are usually constipated. The secre- 
tions in the first and second stages are diminished. The urine is more deeply 
colored than in health, and in vigorous patients it deposits urates on cooling. 
The chlorides are also deficient or absent from the urine so long as the inflam- 
mation is extending. 

In favorable cases in from seven to ten days the heat and thirst decline ; 
the pulse and respiration gradually become less frequent ; the cough looser ; 
the features have a more placid or contented expression ; the appetite 
returns ; and the patient is again amused by playthings. The improvement 
is progressive, but gradual. A slight cough is occasionally observed two or 
three weeks after convalescence is fully established. 

Death in the acute stage of the inflammation commonly occurs from 
asthenia. The pulse gradually becomes more frequent and feeble, the respi- 
ration more oppressed, and finally, near the close of life, the face and extrem- 
ities become cool. Occasionally death results from apnoea, due in great part 
to coexisting bronchitis. In exceptional instances it occurs from convul- 
sions, followed by coma, especially in the first week. In those protracted 
cases in which the inflammatory products have undergone cheesy degenera- 
tion death occurs from asthenia. 

Such are the S3^mptoms and progress of ordinary acute pneumonia in 
children. When the inflammation is subacute, as in those forms of the dis- 
ease which result from collapse or hypostasis, the symptoms are less pro- 
nounced. The respiration in such cases is but moderately accelerated, is 
attended by little pain, and therefore the expiratory moan is often absent. 
An occasional short, dry cough occurs, with so little increase of temperature 
and quickening of the pulse that the pneumonia is often overlooked by the 
physician, the symptoms being referred to bronchitis. Pleuritis seldom occurs 
in connection with this form of pneumonia, except when a small abscess or 
gangrene results in an aff'ected lobule directly under the pleura. A few 
such cases I have observed. 

Tubercular pneumonia extends over much or little of the lung accord- 
ing to the amount of the tubercules. The symptoms are like those of 
severe primary pneumonia, superadded to such as pertain to tuberculosis. 
This inflammation, when once established in the consumptive child, com- 
monly continues till the close of life. I have sometimes had these cases 
under observation several consecutive weeks, even months, and during the 
whole time there was not only acceleration of pulse and respiration, but the 
expiratory moan. As regards pneumonia occurring in whooping cough, it is 
an interesting fact that it sometimes modifies the symptoms of the primary 
disease, so that during the active period of the inflammation the paroxysmal 
cough diminishes, and a short, hacking cough and expiratory moan occur in its 
place. As the inflammation abates the spasmodic cough returns. Pneumo- 
nia occurring in measles is more obstinate, protracted, and dangerous than 
the primary form. It usually commences about the period of the decline of 
the eruption, and in favorable cases continues two or three weeks. It is 
then a sequel rather than complication. 

Physical Signs. — The physical signs of pneumonia in infancy and 
childhood are the same as in the adult, but in a large proportion of cases 
they are less distinct. In a majority of patients under the age of three 
years the crepitant rale is not observed. This is due to the small size of the 



700 PNEUMONIA. 

alveoli at this age. I have now and then detected it in quite young children, 
in whom it is a finer rale than in the adult. If observed it is positive proof 
of the existence of pneumonia. The physical signs, therefore, in the first 
stage of the inflammation are often obscure in consequence of the absence 
of the pathognomonic rale. The vesicular murmur is somewhat intensified 
through the chest, and there is at this stage slight dulness on percussion 
over the seat of the inflammation due to engorgement of the vessels, but it 
is difficult to appreciate this. 

In the second stage, which supervenes more or less rapidly, the physical 
signs are more distinct. Bronchial respiration is in most cases detected 
higher in pitch than the vesicular murmur, with the sound of expiration 
higher than that of inspiration. The voice of the patient is transmitted to 
the ear applied over the seat of the disease, and often a peculiar vibratory 
sensation is communicated to the hand applied over the part, so that it is 
possible to locate the disease by palpation alone. In the second stage, and 
sometimes in the first, coarse mucous rales in various parts of the chest are 
often observed occurring from coexisting bronchitis. 

Percussion in the second stage elicits a dull sound as compared with that 
produced on the opposite side of the chest. . The dulness corresponds in 
extent with the solidification and with the bronchial respiration. 

As the inflammation abates the dulness on percussion gradually dimin- 
ishes, and the bronchial respiration is succeeded by the subcrepitant rale. 
Often for a considerable period after convalescence is established moist rales 
are observed in the chest, and sometimes the dulness on percussion does not 
entirely disappear until the health is fully restored. 

In catarrhal pneumonia these signs are commonly less distinct than in 
the croupous form of inflammation. This is due in part to the limited 
extent of the inflammation, in part, in many cases, to its subacute character, 
and in part to the fact that it is in many patients double, so that we lose the 
aid of comparison. When it results from hypostatic congestion it is nearly 
always bilateral. 

Diagnosis. — It will aid in diagnosis to recollect that under the age of 
three years pneumonia is ordinarily catarrhal, and that it is preceded by and 
associated with bronchitis. Coincident with it, and often preceding its devel- 
opment for a few days, are the usual symptoms of nasal and bronchial catarrh. 
Defluxion from the nostrils and other symptoms due to " taking cold " help 
us to diagnosticate catarrhal pneumonia from the essential fevers, with 
the exception of measles. Croupous pneumonia begins more abruptly, but 
in this form of inflammation the greater extent of pulmonary solidification 
soon gives us clear and unmistakable physical signs. The various forms of 
so-called remittent fever bear considerable resemblance as regards symptoms 
to certain cases of pneumonic inflammation, but in the latter there are more 
acceleration of respiration and greater suff"ering, especially when the child 
is disturbed, than in the former. The physical signs, however, aff"ord decisive 
proof of the nature of the malady — to wit. dulness on percussion, bronchial 
respiration of a higher pitch and harsher than the normal vesicular respi- 
ratory sound, bronchophony, vocal fremitus, etc. 

Difficulty sometimes attends the diagnosis of broncho-pneumonia from 
simple bronchitis. The presence of the expiratory moan, if it be pretty 
constant and marked, afl"ords evidence that the inflammation has extended to 
the lungs, but the physical signs constitute the reliable means of exact diag- 
nosis. They should be carefully noted, in order to determine if there be 
some point of solidification. 

Solidification gives rise to dulness on percussion, bronchial respiration, 
and bronchophony. These three signs coexisting aff'ord sufficient proof of 



CHEESY PNEUMONIA. ' 701 

pneumonia, unless there be tubercular consolidation or possibly collapse super- 
vening on suffocative bronchitis. The history of the case aids in determining 
whether there be either of these diseases. Moreover, collapse occurs later 
after the attack commences than hepatization, and does not produce so dis- 
tinct bronchophony or bronchial respiration as is observed in ordinary cases 
of pneumonia. 

Pleuritis with effusion may present physical signs which bear considerable 
resemblance to those in pneumonia ; but in pneumonia, except when asso- 
ciated with tubercular disease, the dulness on percussion is not so great as 
that from pleuritic effusion. In pleuritic effusion in a young child the respi- 
ratory murmur can often be heard with the ear applied over the liquid, but it 
is indistinct and transmitted through the liquid from a distance. The prac- 
tised ear is able to discover the difference between it and the bronchial respi- 
ration of pneumonia. Vocal fremitus, which is absent in pleuritic effusions, 
is another reliable sign of pneumonia in children over the age of three or four 
years. In younger children it is indistinct. Occasionally the physical signs 
indicate the coexistence of the pulmonary and pleural inflammations. 

In catarrhal pneumonia it is often difficult to determine certainly the 
nature of the disease, since the physical signs, if there be but little extent of 
inflammation, are absent or indistinct. I have often, in post-mortem exami- 
nations, found so small a part of the lung hepatized that it could not possibly 
have produced any appreciable dulness on percussion, bronchial respiration, 
or bronchophony. Such cases often pass for simple bronchitis, and practi- 
cally this matters little, since the treatment required by the two is not dis- 
similar. 

Prognosis. — Primary pneumonia, affecting only one lung, if properly 
treated in most instances terminates favorably in children and even infants. 
If double, it is, as in the adult, much .more serious, and is in certain cases 
fatal. Secondary pneumonia, pneumonia occurring in measles, whooping 
cough, tuberculosis, or resulting from hypostatic congestion in the course 
of some exhausting disease, is, on the other hand, more frequently fatal. As 
death usually occurs from asthenia, the younger the child and more feeble 
the constitution the greater the danger. 

Unfavorable symptoms are an increase of dyspnoea, a pulse becoming more 
and more frequent and feeble, pallor of countenance, inability of the patient 
to support the head, total loss of appetite, refusal to notice or be amused by 
playthings, absence of tears when crying — a symptom which French writers 
have pointed out — and the appearance of pemphigus on the face or elsewhere. 

Indications on which a favorable prognosis may be based are moderate 
acceleration of pulse and elevation of temperature, pneumonia primary and 
limited to one side, ability to support the head or sit erect, being amused by 
playthings, etc. 

Treatment. — The treatment of the two forms of pneumonia — namely, 
catarrhal and croupous, the former occurring chiefly under the age of three 
years and being secondary, the latter occurring in most patients over that 
age — requires to be considered separately, as much as do their symptoms and 
anatomical characters. 

Catarrlial iJiieumonia ^ when developed from and upon a bronchitis, as it 
so often is, requires for the most part the continuance of the remedies which 
are appropriate for the primary disease. (See art. Bronchitis.) But from the 
fact that it is secondary and in children of tender age. and since the danger 
as regards the pneumonia is due to asthenia, more actively sustaining meas- 
ures are demanded than are required for uncomplicated bronchitis. When 
the pneumonia has continued a few days, and often in its commencement, 
carbonate of ammonium and alcoholic stimulants are needed, and the diet 



702 PNEUMONIA. 

from the first should be nutritious. In that forin of catarrhal pneumonia 
which is due to passive congestion or hypostasis, in the causation of which 
debility is an important factor, tonic and stimulating measures are still more 
imperatively required. Frequent change of position is useful in such cases. 

In croupous pneumonia., if seen at the commencement or within a few hours 
of the commencement, an emetic of ipecacuanha may be given, as recom- 
mended by Trousseau. This acts promptly as a cardiac sedative, diminishing 
somewhat the afflux of blood to the lungs and moderating the inflammation. 
It should not be employed except at the period mentioned. 

The abstraction of blood by leeches or otherwise has justly fallen into 
disrepute in the treatment of the inflammations of children, since it is too 
depressing. We have in aconite, antipyrine, antifebrin, phenacetin, efficient 
substitutes for bloodletting, which by their sedative eff"ect on the heart dimin- 
ish the exaggerated afflux of blood to the inflamed lung, and thus enable us 
to meet the indication of treatment in the first stage of the inflammation. It 
is important in all severe cases to preserve the blood and the strength, for the 
danger in the end is chiefly from asthenia, and therefore the use of one of 
the cardiac sedatives mentioned above is preferable to the abstraction of 
blood. 

The following prescription will be found useful in the commencement of 
pneumonia, when the child is restless and has the expiratory moan. It is 
especially useful if, in addition to the general restlessness, occasional twitch- 
ings of the limbs occur, which is a forewarning of eclampsia : 

E. 



Tine, opii deodorat., 


gtt. xy] ; 


Antipyrine, 


gr. xvj ; 


Potas. bromidi, 


.^j; 


Syr. simplic, 


gss; 


Aqufe anisi, 


|iss. 



Shake bottle. Give one teaspoonful every two to three hours to a child of two to three 
years. If nervous symptoms are not prominent, the bromide may be omitted. 

If bronchial respiration, bronchophony, and dulness on percussion are 
present, indicating the second stage of pneumonia, it is better to discontinue 
the use of the antipyrine or other cardiac sedative, unless the temperature 
reach or exceed 104°. If it do, one grain of antipyrine may still be admin- 
istered every third hour to a child of two years, and two grains to one of 
three or four years. 

The remarks made in reference to the use of quinia and digitalis for bron- 
chitis apply with still more force to their use in both the catarrhal and 
croupous forms of pneumonia. In secondary pneumonia and in primary 
occurring in feeble children these agents are in many instances preferable to 
any other medicine for the purpose of reducing the temperature and pulse, 
since they produce this result without depression. They may be administered 
in such cases from the first day. 

In some observations recently made (1880-81) in the New York 
.Foundling Asylum it seemed to us probable that quinine, given in one or 
two large doses at the commencement of acute primary pneumonia, as five 
grains to a child of three years, exerts some controlling effect on the inflam- 
mation, perhaps even rendering it abortive, and that its subsequent use in 
smaller doses may yet supersede in great part that of the cardiac sedatives 
mentioned above. 

When the inflammation begins to abate there is usually progressive im- 
provement. Many now recover with simple mucilaginous drinks or mild 
expectorants useful for the accompanying bronchitis, as chloride of ammo- 
nium in the syrup of tolu. Others require more sustaining measures, and for 



CHEESY PNEUMONIA. 703 

such carbonate of ammonium is preferable, with, perhaps, quinia. In severe 
pneumonia it is of the utmost importance to sustain the vital powers, even 
from the commencement of the inflammation. There can be no doubt that 
the great error in the therapeutic management of children with this malady 
has been the employment of medicines which reduce the strength when 
gentler measures or those of a sustaining nature were needed. Alcoholic 
stimulants are required sooner or later in most cases at an early period in 
feeble children and in secondary forms of the inflammation. Infants may 
take three or four drops of Bourbon whiskey or brandy for each month of 
their age every two or three hours. The diet should be nutritious, consisting 
of milk, animal broths, and the like, unless during the first three or four days 
in robust children. 

The bowels should be kept open as an important part of the treatment of 
croupous pneumonia in its first stages. A small dose of castor oil, Eochelle 
salts, or citrate of magnesia should be given if there be any tendency to con- 
stipation, and repeated from time to time if required. A saline aperient by 
its derivative and refrigerant efi"ect in some cases obviates the necessity of 
employing cardiac sedatives. A laxative enema is preferable for a feeble 
child and in most cases of secondary pneumonia. 

Local treatment is required in all cases ; counter-irritation should be pro- 
duced as soon as possible over the chest by mustard or some stimulating lini- 
ment, and, except at the time of this application, the chest should be con- 
stantly covered with an emollient poultice or with a cloth wrung out of 
warm water and covered with oil-silk. I prefer, however, the constant 
application, under the oil-silk, of the following poultice, made large, but as 
thin as the pasteboard cover of a book, and therefore light : 

R. Pulv. sinapis, - .^ss ; 

Pulv. serain. lini, ^'^"Hj- Misce. 

Vesication, in my opinion, very rarely expedites the cure or benefits the 
patient. The ordinary fly-blister should never be employed ; and if it be 
thought best to vesicate, cantharidal collodion should be prescribed for this pur- 
pose. A safe, almost painless, and at the same time eflacient, mode of apply- 
ing this is in spots as large as a ten-cent piece, half a dozen, more or fewer 
according to the extent of the inflammation, the skin of course remaining 
sound between them. This mode of application obviates the danger of pro- 
ducing a troublesome sore which sometimes occurs in children from the 
ordinary mode of vesication. I have, however, entirely discarded vesication 
in all forms of pneumonia. 

In cheesi/ pneumonia, which is always accompanied by anagmia and great 
reduction of the vital powers, carbonate of ammonium with citrate of iron 
and ammonium equal parts, or cod-liver oil administered three times daily 
with two drops or more of syrup of iodide of iron, will be found useful, 
as is also quinine with iron. Patients require the most nutritious diet and 
alcoholic stimulants. In the local treatment of this form of inflammation 
vesication, even so mild as that by cantharidal collodion, should be avoided. 
Recently in protracted cases of pneumonia attended by wasting, for the pur- 
pose of destroying the tubercle bacillus if it have obtained a lodgment in the 
lungs, there has been recommended the inhalation from a sponge several times 
daily of the vapor of the following mixture : 

R. Creasoti (Merson's), ,^ij ; 

Terebene, 5iij. Misce. 

Add 25 drops to a sponge, and place it near the nose of the patient, especially in sleep. 



704 PLEURISY. 



CHAPTER YIII. 

PLEUKISY. 

The term pleurisy or pleuritis is employed in this chapter to designate 
inflammation of the pleura when not produced by extension of the inflamma- 
tory process from the lung or by the irritation of tubercles upon or under the 
pleura. Catarrhal pneumonia, common in infancy ; croupous pneumonia, 
common in childhood ; pulmonary tuberculosis, not rare in both periods in 
wasted and cachectic children, — are ordinarily accompanied by pleurisy, aris- 
ing consecutively to the lung disease, and limited nearly to the portion of the 
pleura which covers the aff'ected lobes or lobules. But since in these cases 
the pleuritis is subordinate to and dependent on the graver diseases, and is 
comparatively unimportant, it does not require separate consideration. It is 
properly treated of in our books in connection with and as a part of those 
diseases. All other cases of pleuritic inflammation, although presenting wide 
difi'erences in form and clinical history, are embraced under the general term 
pleurisy. 

Frequency. — Pleurisy was formerly supposed to be rare in young chil- 
dren. Even M. Barrier of Lyons, the author of a creditable treatise on dis- 
eases of children, wrote as late as 1860: " Ainsi done, en generalisant les 
faits de Vallieux et les notres, nous pouvons dire : que la pleurisie, depuis la 
naissance jusqu'a I'age de six ans environs, ne constitue presque jamais une 
affection simple, unique, et independante de la pneumonic." But greater 
precision in the examination of cases, more accurate means of diagnosis, more 
knowledge of the nature of diseases, and more frequent autopsies have 
enabled the profession to correct this as well as many other errors, and it 
is now known that primary pleurisy is not infrequent in young children, 
even in infants. In asylums and hospitals for children, in which institutions 
the nature of diseases is more accurately ascertained than in private prac- 
tice — for autopsies are made in the fatal cases — the frequency of pleurisy in 
its various forms — latent, semi-fibrinous, and purulent — is surprising to those 
whose knowledge of the disease has been acquired only through private prac- 
tice. Thus, in the New York Foundling Asylum in the seven months from 
April 1 to November 1, 1879, while there were 35 cases of bronchitis, 21 of 
pneumonia, and 3 of tuberculosis, there were 11 clearly-ascertained cases of 
pleurisy. There can be no doubt that many cases of this malady in young 
children are mistaken by good practitioners for other diseases, especially for 
pneumonia, or, if the pleurisy be to a certain extent latent, for remittent or 
malarial fever or fever due to intestinal irritation. I have records of several 
cases occurring in family and hospital or asylum practice in which children 
perished with a wrong diagnosis or without diagnosis, when the post-mortem 
examination revealed pleurisy, sometimes of long standing. Thus in one 
case of fatal empyema, commencing at the age of six months and continuing 
several months, chronic pneumonia had been diagnosticated by physicians 
known to be thorough in their examination and usually accurate. In another 
case, which proved fatal at about the age of one year, the child, who lived in 
a malarial locality, had been for weeks under treatment for supposed malarial 
disease ; but in this case diagnosis was easy, for at my first visit, which was 
when the child was dying, there was decided dulness on percussion over 
the right side of the chest. In this case the right lung was adherent to 



CA USES. 



705 



the ribs anteriorly and laterally, while posteriorly it was separated by 
pus, which crowded forward the organ so that its posterior surface was 
concave. 

In wards of institutions and in the crowded quarters of the poor pleurisy 
appears to be more frequent than in families in comfortable circumstances. 
Its frequency varies also in different years according to the presence and 
prevalence of its causes. Thus during epidemics of scarlet fever it is more 
common than at other times. 

During several weeks immediately preceding May, 1874, when there was 
no unusual prevalence of the causes or conditions which give rise to pleurisy, 
I noted carefully the character of the sickness in 404 consecutive cases under 
the age of twelve years in private practice, and of these, 2 had primary 
pleurisy, or ^ per cent. This is probably about the usual proportion of 
pleurisies in children in family practice, except when scarlet fever is 
prevalent. 

I have preserved the records of 56 cases of pleurisy in children under 
the age of twelve years, most of them occurring in the institutions which I 
am attending or have attended as physician, and the remainder in private 
practice. The statistics of these cases, embraced in the following table, are 
interesting, as showing the frequency of pleurisy, and pleurisy of the suppura- 
tive form, in young children. The large number of empyemas seen in the table 
does not, however, indicate the true proportion of suppurative to sero-fibrinous 
pleurisies, since protracted and stubborn cases, which are largely empyemas, 
are more frequently brought to institutions for treatment than are those of a 
milder and more manageable type. Thus, in the class of children's diseases 
in the Bureau for the Relief of the Out-door Poor, a large percentage of the 
cases are empyemas which have resisted treatment elsewhere. Besides, pleu- 
risy with little exudation is sometimes latent or so mild that it is overlooked 
or not diagnosticated even by physicians who are thorough and careful in 
their examinations, and I do not doubt that such cases have occurred in the 
institutions and in my private practice during the time in which my statistics 
were collected : 

Af/e (49 Cases). 



Under Two : From Two to Six From Six to 
Months. ! Months. Twelve Months. 



3; all empy- 15; 9 at least 2; both em- 



emas ; 
double. 



empyemas — / 
on right side, 
4 on left side, 
4 double. 



pyemas — 1 
right, the 
other left. 



From One Tear 
to Three Years. 



13; 8 right, 
5 left.^ 

Exudation in 
some sero- 
fibrinous; 
in others 
purulent 



From Three | 

Years to Six ' Over Six Years. 
Years. 



10; 7 right, 
3 left. 

Exudation in 
some sero- 
fibrinous ; 
in others 
purulent. 



6 ; o right, 1 
left ; 1 em- 
pyema. 



Causes. — Primary pleurisy in the child has heretofore been attributed 
to that common cause of inflammations, " taking cold." It is often most 
common in times of changeable temperature. Cachexia is an acknowledged 
predisposing cause, so that children whose blood is impoverished, whether 
from previous disease or from antihygienic influences, are more liable to this 
inflammation than those who possess a sound and vigorous constitution. 
From the operation of this cause a larger proportion of cases occur among 
the children of the city^ poor than among those who are well nourished and 
who live in comfortable circumstances, since the cachectic and ill-cared-for 
are not only more exposed, but are less able to resist noxious agencies. 

45 



706 PLEURISY. 

Pleurisy is not rare in new-born infants, and its cause when thus occur- 
ring is not always apparent. It may sometimes be heedless exposure to cold 
or to currents of air by the nurse, but the common cause at this age is 
believed to be the absorption of septic matter. 

Billard, whose observations were made among foundlings in the Hospice 
des Enfants Trouves, says : " Pleurisy is more common among young infants 
than is generally supposed ; it often appears without the lungs participating 
in the inflammation, I have seen several infants die immediately after birth 
from this affection." He relates two cases of double idiopathic pleuritis end- 
ing fatally at the ages of two and ten days (^Diseases of Infants, page 419). 
Mignot, whose observations were made in the same institution, also records 
16 pleurisies, 5 of which were idiopathic, in 119 dissections of new-born 
infants (^Maladies ])endant le Premier Age'). 

Cases like the following are not infrequent: 

In 1867, I made the post-mortem examination of a foundling who died in 
the New York Infant As3dum at the age of about one month. On each side 
of the thorax, the pleura, costal and pulmonary, was uniformly injected, and 
a small amount of pus, not more than one drachm, was found in one pleural 
cavity, and a still less quantity of pus in the other, with little or no sero- 
fibrinous exudation. There was also pus at the root of each lung, lying not 
entirely upon the free surface of the pleura, but partly underneath it. 

The fact of a double pleurisy without disease of the lungs, which might 
produce it, indicated a constitutional cause. Its system had probably become 
infected by the absorption of septic matter from the umbilical vessels. 

One of the eruptive fevers, scarlatina, not infrequently produces pleurisy, 
occurring as a complication or sequel. This result seems to be sometimes 
due to septic matter in the blood resulting from the action of the scar- 
latinous virus. In other instances it is possibly the result of retained urea 
consequent on scarlatinous nephritis, for pleurisy is a common complication 
of Bright's disease, due, it is supposed, to the irritating property of urea, 
which is excreted upon the pleural surface. Pleurisy in young children is 
sometimes also caused by the discharge into the pleural cavity of some mor- 
bid product, as pus, softened tubercle, or decomposed lung-tissue, which from 
its highly irritating effect causes intense and general inflammation of the 
pleura. I have observed several such cases. 

Thus, in November, 1866, an infant of three and a half months died of 
pleurisy occurring upon the left side. The left lung was firmly bound down 
by adhesions, so as to be reduced to about one-sixth its normal size. On 
attempting inflation of this organ when it was removed from the body, air 
escaped from a small opening in the middle of the upper lobe, and around 
this opening the lung-substance was of a dark reddish color, softened and 
disintegrated. It seemed probable from the appearance that there had been 
hypostatic congestion, or perhaps pneumonia, in the posterior part of the 
lung, and that the loss of vitality and softening had occurred from the slug- 
gish or suspended circulation in the part, and that the fatal pleurisy had 
resulted from a little of this decomposed tissue entering the pleural cavity. 

A case having apparently a similar origin occurred in the New York 
Foundling Asylum in October, 1879 : 

An infant aged five months and a half became suddenly and severely sick 
with pleurisy on the right side, and died in five days. On opening the pleural 
cavity, air escaped. The record of the examination states : " In about the 
middle of the posterior surface of the lower lobe was an opening which 
admitted the tip of the little finger to the depth of one-fourth to one-third 
inch. The lung-tissue seemed to be disorganized and of pultaceous consist- 
ence around the cavity. Through this cavity, which communicated with a 



CAUSES. 101 

bronchial tube, the air had escaped, which was noticed on opening the 
chest." 

Occasionally we meet cases, especially in foundling asylums, in which 
the cause is diiferent from the foregoing, but in some respects similar. An 
indolent pneumonia occurs over a circumscribed area in the posterior part 
of the lung, either from hypostasis or exposure to cold. Minute abscesses 
form in the inflamed parenchyma, not larger than pins' heads or small shot. 
Perhaps they are located in bronchioles, and are produced by the accumula- 
tion of muco-pus, which collects in these tubes, and is not expectorated on 
account of the low vitality and feeble functional activity of the tissues con- 
cerned. These abscesses approaching the pleural surface produce a circum- 
scribed pleurisy of small extent ; and finally one, probably in some sudden 
movement of the lungs, as in crying or coughing, breaks into the pleural 
cavity, causing general purulent inflammation. The following was such a 
case : 

In May, 1859, a male infant aged two months was admitted into the 
Nursery and Child's Hospital. He was delicate, and had what was diag- 
nosticated a mild bronchial catarrh ; but by wet-nursing his general condition 
gradually improved. In July, however, he had repeated attacks of diarrhoea, 
and progressively lost flesh and strength. On August 3d his respiration 
became suddenly accelerated and painful, and death occurred from dyspnoea 
and exhaustion. No cough or other symptom referable to the respiratory 
apparatus had been observed previously to the day of death. 

At the autopsy the intestines were found to present the usual lesions of 
intestinal catarrh of the summer season. The right lung was compressed by 
a sero-fibrinous exudation, though, from the small size of the pleural cavity, 
the quantity of exuded liquid was not more than two ounces. Nearly the 
entire right pleura, visceral and parietal, was covered with fibrin of a creamy 
appearance, and there were loose flocculi in depending portions of the cavity. 
This lung could be inflated, except a little of the lower lobe, which was hepa- 
tized. The left lung also occupied a very small space, being partially col- 
lapsed. It could be readily inflated, when it appeared normal, except a small 
portion in the posterior aspect of the lower lobe, which was partially covered 
with lymph, and was found to contain two abscesses, one closed and the other 
opening externally on the surface of the lung and connecting internally with 
the bronchial tube. On attempting inflation air passed directly through this 
opening. The closed abscess contained from one-third to one-half a drachm 
of pus and disintegrated lung-tissue, as shown by the microscope. 

Another case, showing a similar cause of pleurisy, occurred in a female 
infant of about four months, in the same institution, in November, 1869 : 

She was admitted in October, somewhat reduced from diarrhoea, but her 
health improved partially, though she remained feeble, and the records state 
that she was much troubled with meteorism and occasional pain. On Novem- 
ber 2d she was suddenly seized with great dyspnoea, and died in about fifteen 
minutes. No cough had been noticed or other symptom referable to the 
chest, but there can be little doubt that the occasional symptoms of pain 
referred to in the notes were due to the pleurisy. The body was much 
emaciated, and depending portions showed hypostatic congestion : right lung- 
adherent to diaphragm and to a considerable part of the costal pleura by 
fibrinous exudation ; this lung was somewhat compressed and non-crepitant ; 
its upper lobe floated in water, while its middle and lower lobes sank and 
could be only partially inflated ; this portion of the lung contained a few 
small superficial abscesses, each holding scarcely more than one drop of pus ; 
two of these were empty, and air passed through them on attempting infla- 
tion. They probably, one or both, opened into the pleural cavity during life, 



708 PLEURISY. 

but possibly they were opened in separating the adhesions which united the 
two pleural surfaces at this point ; the pleural cavity contained from two to 
three ounces of liquid, consisting mainly of pus and fibrinous shreds. 

A similar case occurred in the New York Foundling Asylum, in October, 
1879: 

The patient, aged four months, began to be sick October 11th, having 
the characteristic symptoms, and died October 15th. The right pleural 
cavity contained about 5iij of sero-purulent liquid, pressing the lung forward 
and toward the median line. In the posterior surface of the right lower lobe, 
near its base and immediately under the pleura, were three or four small 
abscesses, each not larger than a small drop of pus, and two or perhaps three 
of these had ruptured, so that air escaped from them on attempting inflation, 
while one was closed, the pus in it being visible under the pleura. 

This cause of pleurisy — namely, the bursting of a minute abscess in the 
lung — and that in which a portion of the lung loses its vitality, disintegrates, 
and enters the pleural cavity, are probably not frequent, except in the first 
months of infancy in wasted and ill-conditioned infants in families of the city 
poor and in the asylums. 

A peripharyngeal abscess, descending along the oesophagus, has been 
known to cause fatal pleuritis by bursting into the pleural cavity, and pus 
from carious vertebrae has produced the same result. In January, 1864, I 
presented to the New York Pathological Society the lungs of an infant whose 
history was as follows : 

E, , aged nine months, of strumous parentage, and whose only sister 

had suffered severely from strumous ophthalmia and periostitis, was taken 
sick about December 19, 1863, with febrile symptoms, attended by restless- 
ness, but apparently without any serious indisposition. On the 22d the 
mother called my attention to a prominence just below the right clavicle, 
which proved to be an abscess, and a poultice was applied over it. On the 
24th the prominence suddenly subsided, and immediately the symptoms were 
greatly aggravated. The pulse rose to 160 per minute, the respiration from 
60 to 80, and expiration was accompanied by a moan, indicating acute pleu- 
ritic inflammation. AVithin forty-eight hours after the disappearance of the 
swelling and the exacerbation of symptoms dulness on percussion over the 
right side of the chest was observed, and this increased till it was complete 
from the clavicle to the base of the thorax. The acceleration of pulse and 
respiration continued, the patient grew more and more feeble, and death 
occurred December 31st. 

On dissecting away the integument from the right side of the chest an 
abscess was opened containing nearly one ounce of pus, located at the point 
where the tumor had been observed. At the base of this abscess, between 
two of the ribs, was a small round opening, not much larger than a knitting- 
needle, leading directly into the cavity of the chest, so that on depressing 
the ribs liquid flowed from the pleural cavity. On removing the sternum 
the liquid was found to be sero-fibrinous, with considerable pus in depending 
portions of the pleural cavity. 

I have met one other, apparently almost identical, case, occurring in an 
infant of seven months. 

Pleurisy in the adult is sometimes the result of violence. The most 
notable and unequivocal cases having this origin are those in which the ribs 
are fractured. It rarely happens that we can attribute the pleurisy of chil- 
dren to this cause. I can recollect only one case in which the inflammation 
seemed to be due to violence: 

In September, 1867, an infant of twenty-two months in the almshouse 
on Blackwell's Island, having had a cough half a year and being some- 



CAUSES. 709 

wheat reduced, fell from bed, striking against the left side of the thorax. 
Severe pleuritic symptoms supervened, and the child died of empyema in 
.three and a half weeks. More than a pint of pus was found in the left 
pleural cavity, pressing the heart beyond the median line and the diaphragm 
downward, so that it was convex toward the abdomen. The bronchial glands 
were hyperplastic and slightly cheesy, and a caseous nodule lay in the anterior 
surface of the right lung, which seemed otherwise healthy. The left lung, 
bound down by adhesions, could be partially inflated. Whether or not it con- 
tained small tubercles is not stated in the records. 

The occurrence of the injury just before the commencement of the pleu- 
risy may indeed have been a coincidence, but the mother constantly believed 
that the fall caused the inflammation, and there was no other assignable 
cause. 

It is probable, from the history of this case and the lesions, that the 
cheesy degenerations antedated the fall, and that the pleura was in an abnor- 
mal state and prone to inflammation when the injury was received. 

The etiology of pleurisy in children differs, therefore, from that in adults. 
Certain causes are the same ; but others, as scarlet fever and irritating 
products generated in the walls of the chest and bursting into the pleural 
cavity, are not rare in infancy and childhood, while they seldom occur in 
adults. 

Histories of cases like the above strengthen the belief that pleurisy in 
children frequently, and perhaps usually, has a microbic origin. This belief 
also receives support from the researches of Dr. Henry Koplik of New York. 
An interesting and instructive paper detailing his investigations was read 
before the American Psediatric Society, June 4, 1890. He has kindly fur- 
nished me the following resume of this paper: 

" My methods of investigation were ^strictly in accord with those of the 
Koch school, and the results attained in the above cases correspond closely 
to those of the above authors in the adult subject. The twelve cases could 
be divided from a bacteriological standpoint into four groups. The first group 
includes those cases in which the examination of the pus of the empyema 
yielded either the streptococcus pyogenes or the staphylococcus pyogenes 
aureus. The etiology of this set of cases is still obscure. The exact source 
of these micro-organisms is still a matter of speculation. Whether we agree 
with Weichselbaum, and assume that the empyemas may follow a pneu- 
moniae?), or that these organisms, being present in the subpleural tissues, 
may be enabled to become potent through such a predisposing agent as cold 
or a slight traumatism, the etiology for the present is veiled in doubt. The 
micro-organisms found are not characteristic. The second group of cases 
includes the empyemas of pneumonic character. They are those in which 
the diplococcus pneumoniae (Frankel and Weichselbaum) is found in the 
purulent exudate. In seven cases of the above series this micro-organism 
alone was found in the pus withdrawn from the chest. It was in uncontami- 
nated form, and when cultivated in pure culture and inoculated upon animals 
results were attained identical with those of Frankel and Weichselbaum. 
The isolated presence of such a virulent micro-organism in a pure state in 
the pus of an empyema must lead to the inevitable conclusion that a pneu- 
monia in the lung had preceded or complicated the empyema. In two cases 
of the above seven the pleural exudate, though at first quite serous in cha- 
racter, contained the diplococcus pneumoniae. These cases subsequently 
developed into well-marked empyemas. The pus in the empyemas also con- 
tained only the diplococcus of Frankel and Weichselbaum. 

" The third group includes those cases in which the processes are of a 
tubercular nature. There is only one case of this group to report — a boy 



710 PLEURISY. 

aet. eight years. The tubercle bacilli were found in the pus by cover-glass 
stain only. Experiments upon animals have thus far proved negative. The 
pus in this case was contaminated with streptococcus pyogenes. The patient. 
is still living at the time of writing, but the lung has not expanded on the 
affected side. There are no physical signs in this case of lung tuberculosis 
in the lung of the healthy or affected side of the chest. 

" The fourth group of empyemas includes those cases in which a focus of 
suppuration outside of the chest can with probability be fixed upon as a 
source of infection and as the direct cause of the empyema. In the above 
twelve cases only one, an infant set. four months, could be classed in this 
group. For two weeks preceding the chest trouble the patient had suffered 
from a deep burrowing abscess of one foot. The study of the pus from the 
chest yielded a pure culture of streptococcus pyogenes. A pure culture of 
this injected into animals proved very virulent and fatal. The little patient 
died quickly, even in spite of operation for the relief of the empyema." 

Anatomical Characters. — In the commencement of pleurisy the sub- 
pleural blood-vessels, lying in the connective tissue, and the capillaries of 
the pleura are engorged with blood, producing vascular points and arbor- 
escence, seen through a magnifying-glass of low power. Frequently in chil- 
dren, as in adults, minute extravasations of blood, resulting from extreme 
congestion, occur under the endothelial layer, scarcely perceived by the 
naked eye, but readily seen under the glass. Immediately exudation of 
liquid holding numerous cells begins in the connective tissue which sur- 
rounds the capillaries; the pleura becomes dry and lustreless, while the pro- 
duction and exfoliation of its endothelial cells are greatly increased. These 
no longer present their normal appearance, but are swollen and granular in 
consequence of the inflammation. 

Immediately after these parenchymatous changes occur, serum, fibrin- 
ogenic substance, and leucocytes begin to exude upon the free surface of the 
pleura. The term fibrinogenic substance, instead of fibrin, is employed, 
because it is now believed that fibrin itself is not exuded, but a substance 
which becomes fibrin through the presence and action of certain agents with 
which it comes in contact, among which may be mentioned air, red blood-cor- 
puscles, and even serum, from which fibrin has been precipitated (Virchow, 
Cornil, Ranvier, and others). 

In the exuded liquid, even if it have the appearance to the naked eye of 
ordinary serum, the microscope always reveals the presence of pus-cells or 
leucocytes and red blood-cells, however small their quantity may be. The 
minute rootlets of the lymphatic system, which are interspaces or lacunae in 
the subpleural connective tissue, and which here and there open by stomata 
upon the pleural surface, are clogged by inflammatory products and their 
walls swollen at an early stage (E. Wagner and others). In these lymphatic 
channels both pus-cells and coagulated fibrin are seen by the microscope. 
That pneumonia, whether catarrhal or croupous, seldom occurs in super- 
ficial parts of the lungs without causing inflammation of that portion of the 
pleura which covers the affected lobules is universally known ; but the 
reverse is also true, that pleurisy seldom occurs without causing inflamma- 
tion of the alveoli which are adjacent to the inflamed membrane. The pneu- 
monia thus caused is so superficial that it is very liable to be overlooked at 
the post-mortem examination in the presence of the graver lesions of the 
pleura; but a knowledge of its occurrence is important in diagnosis, for, 
though it may have no greater depth than a line, it is sufficient to produce 
crepitant rales like those in ordinary pneumonia. Therefore, if we hear 
these rales, we may mistake the disease for pulmonary inflammation and 
overlook the pleurisy — an error not unusual in the treatment of children. 



AXATOMICAL CHARACTERS. 711 

Trousseau, who surpassed most of his contemporaries as a clinical observer, 
wrote: "This sound, which is met with in the great majority of cases of 
pleurisy, is in fact a crepitant rale, and I have called it a crepitant rale of 
pleurisy. My interpretation is very simple. Just as we never have erysip- 
elas without engorgement of the cellular tissue, there cannot be erysipelas 
of the pleura or pleurisy without an irritative engorgement of the subpleural 
cellular tissue or of the peripheric pulmonary parenchyma. This fluxion 
naturally carries with it into the pulmonary vesicles a serous exudation. 
.... "We also meet with a fine subcrepitant rale, which is very often heard 
quite at the beginning of pleurisy, and which likewise nearly always con- 
tinues for some weeks." More recent observers and writers fully agree with 
the statement of Trousseau, except that what he designates irritative engorge- 
ment the microscope shows to be a true inflammation of the pulmonary 
alveoli. 

There are four constituents of every pleuritic exudation — to wit, serum, 
fibrin, red blood-corpuscles, and leucocytes or pus-cells ; which last are iden- 
tical in appearance with the white blood-corpuscles and the lymph-corpuscles, 
and the origin of which has been investigated by many microscopists. It is 
convenient to classif}' cases of pleuritis according to the quantity and rela- 
tive proportion of these constituents, as follows: 1st. The plastic, sometimes 
designated dry or adhesive ; 2d. The sero-fibrinous ; 3d. The purulent ; -Ith. 
The hemorrhagic. 

1. Plastic Pleurisy. — In cases which pertain to this group the inflam- 
mation is chiefly parenchymatous, either no exudation occurring upon the 
free surface of the pleura, or if any, whether fibrin, pus, or serum, it is so 
slight that it possesses no clinical importance. The essential anatomical 
changes in this form of pleurisy, as regards the pleural surface, are rapid 
proliferation, retrogressive change or decay and exfoliation of the endothe- 
lial cells, and the sprouting out of granulations which develop into connec- 
tive tissue. In plastic pleurisy there is no compression of the lungs, and 
the pleural surfaces are separated from each other only by the granulations, 
which soon unite with those of the opposite surface. This form of pleurisy 
is not infrequently latent in children, for at the autopsies of those who have 
died of various diseases w^e often observe bands of connective tissue uniting 
the opposite pleural surfaces, when the parents or nurses cannot recall to 
mind any sickness or symptoms such as pleurisy commonly causes. It is 
certain also that plastic pleurisy is often overlooked when not latent, the 
fever and other symptoms being attributed to causes quite distinct from 
the true one. The symptoms and physical signs are obviously less pro- 
nounced in this than in other forms of pleurisy. 

2. Sero-fibrinous Pleurisy. — This is the most frequent of all. It is the 
pleurisy which is usually thought to result from catching cold. The serum 
exudes from the capillaries of the inflamed pleura in very variable quantity in 
diff'erent cases, and the pleural surface is soon covered with a fibrinous layer. 
This may be a mere film or it may attain the thickness of half an inch or 
more. It is usually at first slightly attached, but afterward, from being 
blended with the granulations, it may be firmly adherent. In some cases it 
is quite compact, while in others it has a loose areolar texture, containing in 
its interstices serum and pus-cells. The fibrin is for the most part deposited 
on the pleura, but shreds and flakes of it also float in the serum. In the 
serum, as well as entangled in the fibrin, we find not only red blood-cells and 
leucocytes, but endothelial cells thrown ofl" from the pleura, which, as well 
as those still adherent, are almost always in process of degeneration and 
decay. 

If a perpendicular section be made through the pleura, in this as well as 



712 PLEURISY. 

in the other forms of pleurisy many newly-formed cells, the lymph-corpuscles, 
are observed in the meshes of the subpleural connective tissue, and, as we 
examine the section nearer to the surface of the pleura, these cells are seen 
to be aggregated in masses and held together by a structureless, homogeneous 
matrix. The lymph-corpuscles appear to be the active agents in the forma- 
tion of granulations. They are observed in various stages of transformation 
from the round to the spindle-shaped. The prolongations of the spindle- 
shaped cells unite with each other, so as to form the connective tissues, 
capillaries, and other elements of the granulating surface. That the 
endothelial cells take no part in the production of the new tissue is inferred 
from the fact that most of them present the appearance of retrogressive 
change and decay. The granulations, as they sprout out from the pleura, 
become intimately blended with the fibrinous exudation, and when the effused 
liquid is absorbed they unite with those of the opposite pleural surface, 
forming an organic union, by blood-vessels and nerves, between the lung and 
parietes, the lung and pericardium, or different lobes of the same lung, as the 
case may be. They pass in two or three weeks from embryonic to perfect 
tissue, vessels and nerves grow in them, and they possess henceforth all the 
properties of living tissues ; they are able to absorb ; they are liable to 
inflammation and hemorrhage, and may, in fine, participate in all the altera- 
tions of the organism of which they are a part (Jaccoud). 

3. Purulent Pleurisy. — Although, as stated above, pus-cells are always 
present in the pleuritic exudation, we designate the disease purulent or 
empyema when the cells are so numerous as to render the liquid turbid. 
If there be cloudiness appreciable to the naked eye and due to the pus-cells, 
the case is regarded as one of this form of pleurisy. Purulent pleurisy is 
at first, in a large proportion of cases, sero-fibrinous, becoming purulent after 
some days or weeks — a fact readily ascertained by the use of the hypodermic 
syringe at different periods. In other instances the pleurisy is purulent from 
the first. Pleurisy is in family and in hospital practice more frequently 
purulent in children than in adults, and in ill-conditioned children than in 
those who are robust. It is therefore apt to be purulent in one who has had 
an exhausting disease, as scarlet fever, and in the cachectic children who 
reside in or are brought to institutions for treatment. Thus, in the New York 
Foundling Asylum in 1879 an infant aged two months and three days became 
feverish, and had the expiratory moan and hurried respiration characteristic 
of pleurisy. On the fourth day Dr. Reynolds, who was in attendance, 
inserted the hypodermic syringe and filled it with thin pus. This was, 
apparently, a case of primary idiopathic empyema. Pleurisy is purulent 
when it is produced by the entrance of some irritating substance into the 
pleural cavity, as pus or decomposed lung-tissue. 

The production of pus in the pleural cavity is often surprisingly rapid, 
for, when many ounces have been removed by the aspirator, nearly the 
original quantity is sometimes restored within two or three days. As 
Frantzel says, it does not seem possible that so many pus-cells, which must 
surpass in numbers the aggregate of the white blood-corpuscles, could wan- 
der from the blood-vessel in so short a time, so that we must look for some 
other source of the immense production of leucocytes, in addition to that dis- 
covered by Cohnheini. A large part of the pus-cells is, in all probability, 
produced by rapid segmentation of the lymph-corpuscles. In two cases of 
purulent pleurisy, occurring in infancy, I found pus underlying the pleura 
near the hilus, without apparently any loss of integrity in the pleura, in such 
quantity that it was immediately recognized by the naked eye. Pus under 
the pleura, as well as in the pleural cavity, was apparently due to unusual 
violence in the inflammation and rapid production of leucocytes. 



ANATOMICAL CHARACTERS. . 713 

4. Hemorrhag"ic Pleurisy. — This is not common. I recall but one case, 
a child, in whom the pleurisy occurred as a sequel of scarlet fever. The 
fluid several times removed by the aspirator had a deep reddish-brown color. 
I was apprehensive that the point of the aspirator, by wounding the granula- 
tions, had caused the hemorrhage which stained the pus removed at each sub- 
sequent operation. But, with the care exercised and the great amount of 
blood-stained exudation, it seems almost certain that this was not the true 
explanation, and that it was a genuine case of hemorrhagic pleurisy. 

Hemorrhagic exudation in the pleurisy of children is sometimes due to 
purpura hgemorrhagica, being like the other hemorrhages a symptom of the 
general disease. . In other cases it signalizes the commencement of a new 
inflammation in the vascular granulations of a previous pleurisy. Occurring 
under such circumstances, it is due to the increased fluxion in the numerous 
delicate capillaries of the granulations. Pleurisy due to cancerous or tuber- 
cular formations in or upon the pleura is sometimes hemorrhagic. Jaccoud 
says : " A sero-fibrinous or purulent exudation may be red by the transuda- 
tion of hgematin, without true hemorrhage ; . . , . the red exudations which 
have been observed in scorbutus and marsh cachexia are really due to these 
pseudo-hemorrhages."' In those cases in which there is true hemorrhage, it 
is still uncertain whether rupture of the capillaries or a transudation ordinarily 
occurs, or whether the blood-cells may not escape in both modes. 

A liquid pleuritic exudation, whether sero-tibrinous or purulent, obviously 
produces an important mechanical effect from its location. In young chil- 
dren, especially those enfeebled by sickness, the expansive power of the lung 
is slight, so that it readily yields to pressure applied to its surface, and be- 
comes more and more compressed as the liquid accumulates. Except when 
retained by adhesions, the lung is pressed toward the mediastinum, and at 
the same time carried forward and upward. Patients with pleurisy usually 
lie on the back and aflected side, so that gravitation determines to a consider- 
able extent in what part of the pleural cavity the liquid will collect. In the 
considerable number of post-mortem examinations which I have witnessed of 
children who perished from pleurisy, chiefly empyema, the lung was usually 
attached anteriorly to the thorax from the mediastinum outward, as far as 
the costo-chondral articulations, or farther, except in the lower part of the 
cavity, where there were no adhesions or adhesions only near the medias- 
tinum. There were also attachments along the mediastinum, and attachments 
more or less firm on all sides, anteriorly, laterally, and posteriorly, in the 
upper part of the pleural cavity, toward which the lung was compressed. 
Many variations occur, depending on the amount of liquid and the extent of 
the adhesions; but, judging from autopsies which I have seen, I would say 
that in the average in cases so severe that the question of operative inter- 
ference arises, if we draw a line from the axilla downward and forward to the 
epigastrium, the lung is adherent to the thorax over the space anterior and 
internal to this line, while external and posterior to it the liquid separates 
the lung from the ribs. This fact is important, as indicating the proper point 
for puncturing the chest — namely, below the lower angle of the scapula 
and between the eighth and ninth ribs. One reason why the earlier per- 
formers of thoracentesis were so unsuccessful was that they selected the 
anterior wall of the chest as the point of operation. Now-a-days, however, 
no one would be justified in performing thoracentesis unless he first employed 
the hypodermic syringe and removed fluid at the point which he selects for the 
puncture. The statistics of Mohr relating to lung displacement in empyema, 
chiefly statistics of adult cases, are somewhat difi'erent from my general 
recollection of cases occurring in infancy and childhood, as stated above. In 
23 cases he found the lung free from adhesions and compressed against the 



714 PLEURISY. 

vertebral column and the mediastinum ; in 13 cases the organ was compressed 
from below upward ; in 1 from above downward ; in 4 from within outward ; 
in 4 from behind forward ; and in 4 from before backward. These variations 
depend on the adhesions which the lung happens to contract. Perhaps a 
point a little external to the perpendicular, passinj^ through the angle of the 
scapula, is preferable for puncture, as I have known the lung to be adherent 
to the posterior wall of the chest near the mediastinum when the portion 
farther removed, say two inches from the median line, was separated by 
interposed liquid. 

Sometimes the liquid is collected in multilocular cavities formed by the 
connective tissue, and these frequently intercommunicate. Exceptionally in 
children, as in the adult cases observed by Mohr, when there has been a 
large and rapid liquid exudation or when the disease has been violent and of 
short duration adhesions do not occur. 

On account of the great difference in the size of the pleural cavity at 
different ages during infancy and childhood, the amount of liquid which 
produces that degree of compression of the lung which materially impairs 
its function varies greatly. Kt the age of four months three ounces produce 
complete collapse of lung, so that it resembles a fleshy mass (carnification). 
The largest amount of liquid relatively to the size of the chest in any of the 
cases which I have observed was about one and a half pints in the left pleu- 
ral cavity in an infant that died at the age of twenty-two months in Septem- 
ber, 1867. The heart lay chiefly to the right of the median line, and the 
diaphragm was convex toward the abdominal cavity. The case occurred in 
the almshouse on Black well's Island, and might in all probability have been 
relieved had attention been directed to it sufficiently early. 

Liquid in the left pleural cavity, when considerable, presses the heart 
toward the mediastinum, so that the apex beat, instead of being a little 
internal to the linea mammalis, approaches the sternum. As the heart is 
carried to the right, the beat is felt under the lower end of the sternum, 
and with still greater increase in the effusion the pulsation is detected by 
the finger to the right of the sternum. If the exudation be on the right 
side, the displacement of the heart toward the left is, for obvious reasons, 
less than the displacement toward the right in pleurisy of the left side. 
Much external pressure upon the heart embarrasses its movements and pre- 
vents proper filling of its cavities, while the action of the organ is accel- 
erated so as to compensate. Therefore, the pulse is quick and feeble. 

In one instance in my practice the lower extremities and the portion of 
the trunk below the thorax became cedematous from compression of the 
ascending vena cava, and writers allude to cases in which other vessels and 
ducts, as the thoracic, were compressed so as seriously to embarrass their 
functions. The patient with the oedema was a boy of about four years, 
with empyema of the left side. 

In large effusion the mediastinum is pressed against the healthy lung so 
as to diminish its transverse diameter, and Traube has shown that the effect 
of this is to increase the length of the lung or its vertical measurement. 
Consequently, as the lung on the healthy side extends lower than in the 
normal state, the convexity of the diaphragm on this side is diminished, as 
well as on the affected side, where it is depressed by the effusion. 

The pleura in protracted cases of empyema becomes much infiltrated, 
and from the growth of connective tissue which blends with it is thickened, 
sometimes to the extent of one or two lines. A few months since, in 
removing the lungs from the body of a young infant that perished of empy- 
ema in the New York Foundling Asylum, a portion of the costal pleura, 
two or three inches in diameter, being adherent to the lungs, was detached 



ANAT03IICAL CHARACTERS. 715 

from the ribs. It had a thickness of fully two lines and its free surface was 
rough. 

Occasionally the inflammation extends from the pleura to the pericar- 
dium, producing general pericarditis. I recall to mind 4 cases with this 
complication in which the diagnosis was verified by post-mortem examina- 
tions. All had empyema, 3 on the left, and 1 on the right side. Pericar- 
ditis, always a grave disease, is almost necessarily fatal when thus occurring 
as a complication of empyema. More rarely the inflammation extends from 
the pleura to the peritoneum. One such case occurred in my practice, the 
child dying of empyema on the right side, and at the autopsy we found the 
lesions of a localized diaphragmatic peritonitis of the right side, with a 
fibrinous exudation of small extent on the convex surface of the liver 
directly opposite to that on the diaphragm. We are indebted to Yon Reck- 
linghausen for knowledge of the mode in which inflammation is propagated 
from the pleura to the peritoneum, and the same explanation probably 
applies to its propagation to the pericardium. In the serous covering of the 
diaphragm, pleural and peritoneal, minute stomata have been discovered 
which pertain to the lymphatic system. They open upon the surface of the 
diaphragm, and underneath in the substance of the diaphragm connect with 
lacunae or interspaces from which the minute lymphatic vessels originate. 
These stomata and lymphatic spaces, pervious in their normal state, are usually 
clogged, as has been stated above, by inflammatory products when the serous 
membrane is inflamed. Occasionally the inflammation traverses these lym- 
phatic channels from one surface to the other, from the pleura to the peri- 
toneum, thus causing by extension a circumscribed peritonitis. 

The changes which the inflammatory products undergo are the following : 
With the abatement of the inflammation the liquid portion begins to be 
absorbed, though absorption is much more tardy than in non-inflammatory 
eff"usions, since the absorbents are to a great extent covered and clogged by 
fibrin and pus. The serum is first absorbed, and the flocculi of fibrin sink 
into depending portions of the cavity or become attached to the fibrinous 
layers or the granulations upon the pleural surface. The pus-cells and the 
fibrin, whether in flocculi or layers, begin to undergo retrogressive change. 
They become granular from fatty degeneration, liquefy, and are absorbed. 
Sometimes portions of these degenerated products which are not absorbed 
form inert caseous masses in recesses of the cavity or between the bands of 
connective tissue, where they remain unchanged for years. With few excep- 
tions, those who recover from an attack of pleurisy experience no subsequent 
ill-efl"ect, though the bands and patches of connective tissue are permanent. 

Pus always possesses irritating properties. Decomposed and putrid pus 
(ichor) is very irritating. Empyemic pus, therefore, like pus in other situa- 
tions, now and then produces ulceration or necrosis of the pleural surface by 
which it is confined, and in consequence of its destructive action it sometimes 
establishes an outlet by which it escapes, with relief of the patient and cure 
of the disease. The chest-wall is thinnest anteriorly in the inframammary 
region, and at this point the pus, w^hen it makes its way through the thoracic 
wall, usually points and discharges. The fistulous opening thus produced 
continues many months, until the pleural cavity is gradually obliterated by 
the adhesions and the patient recovers. 

By a similar destructive process in the pulmonary pleura pus occasionally 
escapes into the bronchioles and is expectorated. This mode of cure appears 
to be common in children, for my attention has not infrequently been called 
to the fact that children, during the progressive but slow convalescence from 
empyema, expectorated large quantities of muco-pus, although in some of 
the cases pus had been removed by the aspirator or trocar. Frantzel makes 



716 PLEURISY. 

the remark — which is fully sustained by clinical experience in this country — 
that although an opening is made in the lung by the necrotic or ulcerative 
process, so that pus escapes into the bronchioles, air does not pass from them 
into the pleural cavity. Pyopneumothorax is very rare in the empyema of 
children, except as air is admitted in the operation of thoracentesis. 

As the liquid is absorbed the compressed lung ordinarily expands in pro- 
portion to the absorption, so that more and more air enters its alveoli. But 
frequently, in cases of long duration, the absorption proceeds faster than the 
expansion, so that the ribs on the alFected side sink below their normal level. 
As a consequence, the intercostal spaces are narrowed, the shoulder is depressed, 
and the dorsal portion of the spinal column bends to accommodate the ribs, 
so as to be concave toward the affected side. It is very rarely that the 
deformity thus produced is permanent. Though the newly-formed bands and 
patches of connective tissue may so bind the lung that its return to the nor- 
mal state is tardy, yet with few exceptions the alveoli one after another open 
to admit air, and when full inflation is attained the symmetry of the chest -is 
restored. But there are rare cases in which the newly-formed connective 
tissue is firm and unyielding almost as cartilage, and lime salts are some- 
times deposited in it, forming a calcareous plaque which invests-the lung like 
a cuirass. An unexpanded lung with such a covering obviously can never 
afterward be fully inflated. T can recall to mind, however, only one case of 
permanent complete collapse or carnification of lung resulting from pleurisy. 
The inflammation, which was treated by the late Dr. Cammann, occurred in 
childhood, and several years afterward, when the patient reached womanhood, 
although the general health was good, there were physical signs of an 
unaerated lung and the consequent deformity (depressed shoulder and ribs 
and bent spinal column). Pleurisy with its granulations and retrogressive 
products affords one of the conditions in which tubercles are developed, so 
that we sometimes find at the post-mortem examination of cases which have 
been protracted, " miliary tubercles in the pleura, while chronic phthisis and 
general tuberculosis are absent" (Delafield). 

From the intimate relation of the heart to the lungs this organ obviously 
suff"ers severely in every large pleuritic exudation. Total compression of a 
lung arrests one-half of the circulation through the pulmonary artery, except 
as the increased flow in the opposite lung serves for compensation. Hence in 
cases of large eff"usion which end fatally we commonly find the pulmonary 
artery and the right cavities of the heart distended with blood and clots, 
while the left cavities, having received a diminished quantity of blood, are 
probably empty. 

Symptoms. — As has been stated above, pleurisy in children is sometimes 
latent or attended by symptoms so mild as to attract little attention even 
when there has been general inflammation of the pleural surface with much 
eff"usion. Both primary and secondary pleurisy may present this form, 
latency being more frequent the younger the patient. In feeble, cachectic 
children, with blood thin and impoverished, pleuritic symptoms, as pain, 
dyspnoea, and fever, are less pronounced than in the robust, and hence 
latency is more common in the tenement-house population of the cities and 
in institutions than in the better walks of life. The following is a not infre- 
quent example of latency : A feeble infant, aged five months and twenty- 
eight days, died suddenly in the Nursery and Child's Hospital in December, 
1870. The attention of the resident physician had not been called to it, as 
it was not supposed to be sick, except that it was ill-nourished and its general 
condition bad. The nurse who had charge of the ward stated that it pre- 
sented no symptom of acute disease, unless a slight cough during the three 
or four days preceding its death. Percussion over the right side of the chest 



SYMPTOMS. 717 

of the corpse gave a flat resonance, and at the autopsy the right lung was 
found compressed, nearly or quite destitute of air, and covered by a loose 
fibrinous layer three-fourths of an inch thick in places, and a moderate serous 
exudation. 

Ordinarily, acute idiopathic pleurisy in children begins quite abruptly, 
and with symptoms which attract attention from the first. Probably in most 
instances it is preceded by rigors or a chilly sensation, but this usually escapes 
notice, if it be present, in patients under the age of five or six years. Fever, 
fretfulness, and a physiognomy indicative of pain are the common initial 
symptoms. If the patient be an infant, the fretfulness closely resembles 
that produced by colic, for which I have on several occasions known it to 
be mistaken by the attending physician. 

The symptoms of pleurisy are twofold — namely, the constitutional, or 
such as are common to all inflammations, and the local, or those referable 
to the chest. Various observers have noted the position in which patients 
lie in bed as indicating the seat of the inflammation. It has been stated that 
adults, in the commencement of pleurisy, ordinarily obtain most relief with 
a decubitus on the sound side, but when effusion has occurred they lie on the 
affected side, unless there be marked dyspncea, which is most relieved by a 
semi-erect position, which allows greater descent of the diaphragm. I have 
not noticed that children with pleurisy prefer any fixed or uniform position, 
except there be marked dyspnoea, which may prompt them to elevate the shoul- 
ders. The patient in the acute stage is commonly quiet when he lies in the 
position which he selects, and if disturbed from it becomes more fretful, his 
cough more frequent, and his suffering apparently increased. 

In ordinary cases the temperature rises on the first day to 102° or 103°. 
If it be more elevated than this there is usually a complication. The tem- 
perature begins to abate when the exudation has occurred. In suppurative 
pleurisy the fever is more protracted, often continuing for weeks or months, 
presenting, after the acute stage has passed, the characters of hectic fever, 
with morning abatement and evening recrudescence. In weakly and ana3mic 
children, even when the pleurisy is pretty severe and most of the usual symp- 
toms are present, the temperature may be but slightly elevated. Thus in one 
of the institutions with which I am connected, in a young infant whose fret- 
fulness was during the first twenty-four hours ascribed to colic the axillary 
temperature during the first three days never rose above 100°. 

The pulse in the acute stage is usually between 100 and 130 per minute, 
but in young children who are restless it is often more' frequent than this 
during the first week. It is accelerated as long as the temperature is elevated, 
but in sero-fibrinous pleuritis after exudation has occurred its frequency 
diminishes unless the heart be compressed. Compression and imperfect or 
partial filling of the cavities of the heart produce a feeble and rapid pulse. 
In empyema the pulse is accelerated as long as pus is confined in the pleural 
cavity, unless its quantity be small. 

Headache, usually frontal, is frequent during the febrile stage. Convul- 
sions, which occasionally occur in the beginning of pneumonia, are rare. 
Pain in the chest on the affected side is common, and is therefore a valuable 
diagnostic symptom, but it is often so slight as to be overlooked in infants 
and feeble children. It is increased by movements of the chest-walls, as in 
full inspiration, by coughing, and when pressure is made by the fingers in 
the examination. Its common seat is between the fifth and eighth ribs, exter- 
nal to the linea mammalis, but there are many cases in which the pain is 
referred to some other part, as the infraclavicular, mammary, inframammary, 
or even the scapular or infrascapular, region. Rarely, it is referred to the epi- 
gastric or umbilical region, or even, it is said, to some point upon the sound 



718 PLEURISY. 

side of the thorax. This location of the pain at a point distant from the seat 
of the inflammation is attributable to the anastomosis of the intercostal nerves 
with those of the opposite side of the chest or with those which ramify in 
the abdominal walls. 

The pain of pleurisy, as it ordinarily occurs, has received difl'erent expla- 
nations. It has been attributed to tension of the pleura, to friction of the 
pleural surfaces on each other, and to extension of the inflammation to the 
neurilemma of the minute nervous branches of the pleura. All these causes 
apparently act in producing it, but the persistent pain in the first days of 
pleurisy, though increased by motion, is probably due in great part to that 
last mentioned. Pleuritic pain is sharp or stitch-like. It begins to abate in 
a few days, and in a large proportion of cases ceases by the fifth or sixth 
day. or is no longer noticed except in coughing or during sudden movement 
of the chest. 

The respiration is accelerated, as in all febrile diseases, but it is more rapid 
than in inflammatory ailments which do not involve the thoracic organs, on 
account of the pain experienced on full inspiration. The patient instinctively 
avoids full inflation of the lungs, and the breathing is consequently rapid, to 
compensate for incompleteness of the inspiratory act. 

In ordinary attacks of pleurisy painful and hurried respiration is of short 
duration. It becomes easier and more natural toward the close of the first 
week. In subacute and chronic cases the rhythm and frequency of respi- 
ration diff"er but little from the normal. 

A cough, whatever the form of pleurisy, is one of the earliest symptoms. 
It is short, frequent, and dry, and in the most favorable cases begins to dimin- 
ish in the second week. A loose cough is due to accompanying bronchitis or 
broncho-pneumonia, or, at a late stage of the disease, to escape of pus from 
the pleural cavity into the bronchial tubes. 

Little need be said in regard to symptoms referable to the digestive appa- 
ratus. Vomiting is common on the first and second days. Thirst, loss of 
appetite, and consequent loss of flesh and strength, are uniformly present. 
In empyema, which from its nature is protracted, nutrition is always greatly 
impaired. The surface presents an anaemic appearance, the flesh is soft and 
flabby, and the emaciation is progressive till the pus is evacuated. 

Physical Signs. — In children above the age of three or four years, the 
physical signs difl"er but little from those in adult cases, but under this age 
there are certain difl"erences which the practitioner should know. We may, 
in the commencement of the attack, notice diminution in the movement of 
the chest-walls on the aff"ected side, since the patient instinctively endeavors 
to repress respiration on that side in order to lessen the pain. In severe 
cases the epigastrium and hypochondria are sometimes depressed during 
inspiration (the so-called abdominal respiration), but this sign is less common 
and less marked than in severe bronchitis, and when present it may be largely 
due to accompanying bronchitis. After efl"usion has occurred and the pain 
has abated or is slight, the respiration is less accelerated than at first, and it 
may be nearly or quite normal. 

Inequality of the two sides produced by the liquid is more common in 
children of an advanced age than in those under the age of three or four 
years. In infants, even when there is a large liquid exudation, the bulging 
is often so slight that it is scarcely appreciable either by sight or measure- 
ment, and in not a few there is no apparent difl'erence in the circumference 
of the healthy and afl'ected sides. I have made measurements in infantile 
pleurisy during the stage of efl"usion, and been unable to convince myself 
that there was any diff'erence, although other signs indicated the presence of 
an eff"usion which filled at least one-half the pleural cavity. I explain this 



PHYSICAL SIGNS. 719 

fact in this way : The lungs of an infant, especially of one reduced by sick- 
ness, are yery liable to a state of semi-collapse or partial inflation in their 
whole extent and of complete collapse of their thin borders, as of the tongue- 
like process of the left upper lobe, which lies oyer the pericardium, and of 
the margins of the lower lobes, which lie in the angle made by the thorax 
or diaphragm. This occurs in the weakly infant eyen when there is no 
obstruction to the entrance of air, and the liability to it is greatly increased 
by external pressure applied to the lung, as from a pleuritic effusion, so that 
the lung recedes, becomes compressed, and unaerated before the ribs yield to 
the pressure. If the exudation cease as soon as the lung is collapsed, there 
is little or no outward displacement of the ribs and the intercostal spaces are 
not elevated. It is obviously very important to know this difference between 
infantile and adult cases, as it has a bearing upon the diagnosis between 
pleurisy with effusion and pneumonia. 

Palpation. — In adults and in children with strong voices, if the lung 
deprived of air, either by compression or an exudation within its alveoli, lie 
against the chest-wall, speaking or moaning produces a vibratory sensation 
which is communicated to the hand placed upon the chest. The fremitus is 
feeble or not appreciable when the voice is feeble. Therefore, in infants 
whose vocal cords are small, and particularly in infants reduced by sickness, 
this sign is ordinarily absent or so slight that it is detected with difficulty, 
while in older and robust children it is distinctly perceived. If the condition 
be otherwise favorable for the production of fremitus, but the lung be pressed 
away from the ribs by an intervening liquid, no vibration is felt when the 
patient speaks or cries. But if, in the same case, the fingers be removed to 
the suprascapular, axillary, infraclavicular, or mammary region, where the 
compressed lung comes in contact with the walls of the chest, fremitus may 
be perceived. Palpation also enables us jto a.scertain the point of apex-beat 
of the heart, variation of which from the normal size being one of the most 
conclusive proofs of a pleuritic effusion. 

Percussion. — In the first hours of pleurisy there is either no perceptible 
change in the percussion sound, or the resonance is slightly diminished from 
the fact that inspiration on the affected side is resisted by the patient and the 
lung is only partially inflated. When exudation occurs, if there be a thin 
layer of liquid over the lung the percussion sound is tympanitic. It has, 
therefore, this quality at an early stage in the inframammary, mammary, and 
perhaps infrascapular regions when the amount of liquid is small, and at a 
later stage, when the quantity of liquid is greater, the percussion sound over 
the lower part of the chest is dull, while that over the central or upper part 
is tympanitic. Entire filling of the pleural cavity with liquid, and total 
exclusion of air from the lung, give rise to a dull or flat percussion sound 
over every part from the apex to the base. It may be stated as a rule in the 
pleurisy of children that at a certain stage of the effusion percussion pro- 
duces a sound which is either decidedly tympanitic or which partakes of the 
tympanitic character. Skoda attributed the occurrence of tympanism to the 
fact that a lung still aerated vibrates better if surrounded by a thin layer of 
liquid, and consequently gives better resonance than when it lies against the 
chest-walls. 

When the exudation is so great that the lung is totally compressed and 
removed to a distance from the chest-walls, the finger in percussing experi- 
ences a sensation of solidity or resistance and there is no longer any vibra- 
tion of the ribs. Consequently, the percussion sound is dull or flat, as over 
any solid body, differing from that in pneumonia, in which there is still some 
vibration of the chest-walls and the dulness is not absolute. In pleurisy, 
therefore, there is, according to the amount of exudation, either nearly the 



720 PLEVBISY. 

normal percussion sound, as at the beginning of tlie attack and in any stage 
of plastic pleurisy (pleuresie seche), or a zone of dull sound below and 
another of tympanitic sound above, or a zone of normal resonance above 
and one of dull resonance at the base, with an intervening one of tympan- 
ism ; or, finally, there is absolute dulness from the clavicle to the base of the 
chest. 

It very rarely happens in the child that the level of the fluid changes by 
changing the position, on account of the adhesions, so that this sign, described 
in the books as one of great importance in diagnosis, affords very little assist- 
ance to diagnosis in children. 

Auscultation. — In the beginning of pleurisy auscultation aff"ords but slight 
information, except that the practised ear may detect a little diminution in 
the fulness of the respiratory act in the lung whose pleura is inflamed, and 
perhaps a slightly exaggerated respiration in the other lung. But after 
twelve or fifteen hours, when exudation begins to occur upon the pleural 
surface, we may hear the dry friction sound, which can be imitated by push- 
ing the finger strongly across the dry palm of the hand. It is only heard in 
occasional cases, since the physician may not make his visit at the proper 
time for hearing it or he does not apply the ear over the proper place. 
Frantzel says : " We shall scarcely ever fail to find the friction sound in 
recent pleuritis if we look for it early and diligently in some circumscribed 
spot." I do not think that this remark, however true it may be of adult 
cases, is entirely correct as regards children, for it is only in exceptional 
instances that it can be heard in them. It occurs both during inspiration 
and expiration, and it does not disappear after coughing. Being produced 
upon the surface of the lung, it seems near the ear of the auscultator. Per- 
haps it is not observed during several consecutive respirations, and then a 
deeper inspiration causes the pleural surfaces to glide upon each other, and 
it is detected. The friction sound as sometimes heard is well described by 
the term " scraping," and in other cases by the term " creaking," as was 
noticed by Hippocrates, who compared it to the creaking of leather. 

In some patients it is heard for a brief period, and does not recur, and it 
may be detected only during strong and deep respiration or in coughing. It 
disappears entirely when the accumulation of liquid prevents contact of the 
surfaces. After absorption of the liquid the friction sound may reappear, 
and in certain patients it is heard only at this time — to wit, in the third 
stage. 

x\n interesting and common sound heard on inspiration is the so-called 
crepitant rCde of plevrisy, produced in the superficial alveoli. The remarks 
made by Trousseau upon it have been already given. As stated above, the 
inflammation extends from the pleura to the pulmonary vesicles which lie 
directly underneath, and as soon as exudation occurs within them the ana- 
tomical conditions are present in which the crepitant rale is produced, as in 
the ordinary form of pneumonia. This rale may obviously be heard before 
any eff"usion takes place upon the free surface of the pleura, and it continues 
until the alveoli are so compressed by the plueritic exudation that they no 
longer admit air. 

The exudation in the pleural cavity changes the character of the respira- 
tory sound. A thin layer of liquid over the lung causes diminution in the 
force of the vesicular murmur, and soon an expiratory as well as an inspira- 
tory sound begins to be heard. This modified vesicular murmur is weak, 
and more distant from the ear than the respiratory sound of health. When 
the exudation is sufficient to close the alveoli, while the air still traverses the 
medium-sized bronchial tubes, we notice a tubular or bronchial hniit. If the 
small and medium-sized tubes are compressed while the air enters the large 



PHYSICAL SIGNS. 721 

tubes, the respiratory bruit may be amphoric. Total absence of respiratory 
sound results from complete collapse of the alveoli and consequent exclusion 
of air from them, and arrest of the movements of the air in the tubes of the 
affected side. Jaccoud says : " Regarded as a sign of the quantity of the 
effusion, the modifications of the respiratory hrult and of the respiration may 
then be arranged in an increasing series, as follows : diminution of the vesic- 
ular murmur ; feeble respiration (soujfle doux) ; no sound and feeble respira- 
tion ; bronchial respiration ; no sound and bronchial respiration ; no sound 
and cavernous respiration ; general absence of sound (silence general). The 
replacement of an inferior term of the series b}^ a superior term implies an 
augmentation in the quantity of liquid, and in general the passage of a 
superior term to an inferior term denotes a diminution of the effusion." But 
this statement relating to the effect upon the auscultatory sounds of the 
increase and decrease of the liquid must be modified as regards patients 
under the age of five years. In such patients it is rare, however great the 
effusion, that respiration is not heard when the ear is placed over the liquid. 
This is due to the small size of the pleural cavity, and the consequent ready 
transmission of sound from the centre of the thorax to its periphery. Accord- 
ing to the amount of exudation and the degree of compression, the respira- 
tory sound is a faint and distant vesicular, or broncho-vesicular, or bronchial 
murmur, and its character is found to vary from one to the other of these 
sounds as we apply the ear over different parts of the chest. 

When the inflammation is active and the exudation occurs rapidly, bron- 
chial respiration may be heard as early as the second or third day, or even by 
the close of the first day, in the infrascapular region. If, on the other hand, 
the inflammation be chiefly plastic or the exudation of liquid be slow and its 
quantity small, the respiratory murmur may be vesicular, though faint and 
distant, during the whole course of the attack. Sometimes when the mur- 
mur is vesicular in the greater part of the lung, broncho-vesicular or bron- 
chial respiration is heard over a limited area, where the effusion happens to 
be sufiicient to produce requisite compression of the lung. 

The voice of the patient when auscultated over the affected side has a 
character which corresponds with and varies according to the respiratory 
murmur. Yocal resonance is feeble or absent if the respiratory murmur be 
vesicular. If it be bronchial, the auscultated voice is more distinct, having 
the character known as bronchophony, or when there is a moderate quantity 
of liquid over the lung, so that this organ vibrates, it may have that modifi- 
cation of bronchophony known as aegophony. Occasionally we can hear the 
voice as a confused and distant sound when the quantity of liquid is so 
great that respiration is inaudible. The signs derived from the auscultated 
voice are not. as is well known, pathognomonic of liquid effusion. Bronchoph- 
ony is more common and distinct in pneumonic or tubercular solidification 
of lung than in pleurisy, and even aegophony may be produced without the 
presence of a liquid by '• pleural membranes realizing certain physical con- 
ditions " (Jaccoud). But since the auscultated voice is weaker in children 
than in adults, we often do not hear it in infants and ill-conditioned children, 
even when the anatomical conditions as regard the lungs and pleural cavity 
are favorable for its transmission. 

In children, as in adults, bronchial rales are common in pleurisy, dry or 
moist ; coarse when produced in the larger tubes, or fine when occurring in 
the finer tubes. 

Diagnosis. — Ordinarily, a careful observance of the history, symp- 
toms, and physical signs enable the physician to make a positive diag- 
nosis. Obscure or doubtful cases occur chiefly in infancy. Circum- 
scribed pleurisy or pleurisy attended with little or no liquid exudation 
46 



722 PLEURISY. 

is obviously likely to be overlooked and its symptoms mistaken for tbose 
of another disease. 

Pleurisy before the stage of exudation may be mistaken for pneumonia, 
since the prominent symptoms in the commencement of the two diseases are 
similar. But in pleurisy there are commonly greater acceleration of pulse 
and respiration, greater suffering as evinced by the features, greater tender- 
ness on percussion or on pressing the chest-wall, and a more decided expira- 
tory moan, while the patient probably endeavors to repress respiration on the 
affected side, so that inflation of the lungs is partial and shallow. It will aid 
in the diagnosis to recollect that in children under the age of five years acute 
pneumonia is in most instances catarrhal, and not croupous, and is preceded 
and accompanied by severe bronchitis, being due to downward extension of 
the inflammation from the bronchial tubes. It therefore does not begin with 
the abruptness of pleurisy. 

Pleurisy with effusion may be mistaken for pneumonia in the stage of 
solidification, for hydrothorax, or, on the left side, for pericardial effusion, or 
vice versa. But the percussion sound over a pleuritic exudation is either 
tympanitic or flat, while over a lung solidified by inflammation it has some 
resonance, though dull. There is also a sensation of greater resistance and 
solidity in percussing over a pleuritic exudation than over an inflamed lung. 
Moreover, the respiratory murmur, whether vesicular, broncho-vesicular, or 
bronchial, is more distant and less distinct to the ear of the auscultator 
when applied over a liquid than over a solidified lung. 

A pleuritic exudation, unless slight, also changes the apex-beat of the 
heart, pressing it toward the median line in left pleurisy, and away from 
the median line in right pleurisy, as has been stated above — a change not 
observed in pneumonia. Bulging of the intercostal spaces, expansion of 
the chest-walls, change in height of the fluid by change in the position of 
the child — important signs in the diagnosis of adult pleurisy — are, as we 
have seen, commonly absent in young children, even when there is abundant 
liquid effusion, but they are sometimes observed in children of a more 
advanced age. Bronchophony and vocal fremitus, signs of pneumonic solid- 
ification, are absent or so feeble in the pneumonia of young children that 
their absence cannot be regarded as indicative of the presence of pleuritic 
effusion, except in children over the age of four or five years. Moreover, 
these signs, when present, do not necessarily indicate pneumonia, for if in 
pleuritic effusion the ear or hand be placed over a part of the chest where 
adhesions have united the lung to the ribs, and the child be of such an age 
that the vocal cords have sufiicient vibration, both bronchophony and the fre- 
mitus may be perceived. The absence or presence, therefore, of vocal fremitus 
and bronchophony affords only limited assistance in the differential diagnosis 
of pleurisy and pneumonia in young children. In those of an advanced 
age, whose vocal cords have greater vibration, it aids in the discrimination 
of doubtful cases, especially if the examination be made in the infrascap- 
ular region, which corresponds with the location of the liquid, if any be 
present. 

A pleuritic effusion is distinguished from hydrothorax by the fact that 
the latter is usually bilateral and of slow increase, without symptoms refer- 
able to the chest, except when there is considerable effusion, which causes 
more or less dyspnoea. Pleurisy, unlike hydrothorax, causes fever and other 
constitutional symptoms, and also a cough, pain in the chest, and early 
embarrassment of respiration. Moreover, hydrothorax seldom occurs, except 
from cardiac or renal disease or scarlet fever. 

A greatly distended pericardial sac simulates in some degree a pleuritic 
effusion on the left side, but the absence of symptoms which pertain to 



PROGNOSIS. 723 

pleurisy, as the cough, stitch-like pain in the chest, the localization or greater 
distinctness of the dull sound on percussion in the cardiac region, absence 
or feebleness of the apex-beat, and indistinctness or distance of the heart- 
sounds, will preserve the observant physician from error of diagnosis. 

Prognosis. — In mild cases attended with little exudation the inflamma- 
tion soon begins to abate, and by the close of the second week the symptoms 
have nearly disappeared. In plastic and sero-fibrinous pleurisies recovery may 
be confidently expected, unless there be some grave complication, or perchance 
syncope should occur from large and rapid eiFusion. A large effusion, what- 
ever its character, especially if located on the left side, often causes such a 
twist in the great vessels within the thorax as seriously to retard the circu- 
lation of blood and endanger life. In effusions of the left side the heart is 
often carried so far toward the right that the ascending vena cava, where it 
emerges from the central tendon of the diaphragm, is bent at an angle so as 
seriously to obstruct the return of blood from the lower half of the body, 
and consequently a reduced quantity of blood reaches the right cavities and 
the pulmonary artery. The result is a diminished flow of blood in the sys- 
temic circulation, with ansemia of important organs, as the brain. The great 
arteries connected with the heart are also more or less bent in cases attended 
by displacement of this organ. In effusions on the right side the right auricle 
and ventricle sometimes do not expand to the normal extent during the dias- 
tole, on account of the pressure of the liquid, and the result is similar to 
that in effusions on the left side as regards obstructed circulation and anae- 
mia of important organs. Therefore, patients with large pleuritic effusions, 
whether left or right, are liable to sudden fainting and even to fatal syn- 
cope. Fortunately, with our present improved methods of thoracentesis 
children need not perish in this way if the operation be resorted to at the 
proper moment. There is another danger. When, in consequence of the exu- 
dation, the lung is so compressed that its function is nearly or quite lost, 
the sound lung obviously receives an augmented supply of blood. It is 
therefore very liable to sudden congestions and transudation of serum 
(oedema). If this occur, the dyspnoea is augmented and the condition is one 
of utmost peril. Death may result from this state. 

The prognosis obviously varies according to the cause of the inflamma- 
tion and the quantity and nature of the exudation. Idiopathic pleurisies do 
better, as a rule, than those which occur as a complication or sequel of some 
other disease. Absorption is more rapid in the beginning of convalescence, 
when the fluid is thin, than at a later period, when it has greater consistence. 
Fibrin, whether flocculent or laminated, is necessarily slowly absorbed, first 
undergoing fatty degeneration and liquefaction. Empyema, if not relieved 
by operative measures, continues many months ; even after pus is let out con- 
valescence is slow. In the very considerable number of empyemic cases 
which have from time to time been brought to the class of children's dis- 
eases in the Bureau for the Relief of the Out-door Poor the histories com- 
monly showed that the disease had continued from three to six months, with 
progressive loss of flesh and strength. Nevertheless, after proper evacuation 
of the pus and the establishment of a fistulous opening the majority have 
gradually recovered, death in the unfavorable cases being commonly due to 
extreme prostration with perhaps fatal organic changes, as amyloid degenera- 
tion and tuberculosis. 

Secondary pleurisy occurring in a reduced state of the system, as after 
scarlet fever, and pleurisy complicated by a grave disease, as pericarditis or 
pneumonia, are always dangerous to life. 

It is the common belief that pleuritic effusions involve greater danger on 
the left than on the right side, from the fact that the former produces more 



724 PLEURISY. 

immediate and direct pressure on the heart and causes a greater twist in the 
vessels, but Leichtenstern^ states that in 52 cases of sudden death from pleu- 
ritic effusions, 31 were right and 20 left pleurisies. The walls of the right 
cavities of the heart, upon which the liquid in the right pleural cavity 
directly presses, are thinner, and therefore more yielding, than the walls of 
the left cavities. The records of the cases collected by Leichtenstern show 
that sudden death sometimes results from extensive and far-reaching thrombi 
in the right cavities of the heart and in the superior vena cava, or from emboli 
detached from the thrombi and intercepted in the pulmonary artery. In 
grave cases attended by large effusion sudden death sometimes occurs after 
some exertion on the part of the patient, as after vomiting, severe coughing, 
or hurried rising to the erect position or lifting a heavy weight. It is believed 
that under such circumstances there is a retarded flow of blood through the 
lungs and into the left cavities of the heart and the aorta, so that sudden 
and fatal anaemia of the brain is produced. 

As already stated, death may occur in protracted cases from amyloid 
degeneration of important organs, as the kidneys and liver. This can some- 
times be detected by enlargement of liver and spleen and the occurrence of 
albuminuria. 

It is evident that the prognosis varies greatly according to the degree of 
dyscrasia. In profound blood-poisoning, whether scarlatinous, ursemic, or 
septicaeraic, pleurisy is always grave. Septic pleurisy, which occurs for the 
most part in new-born infants during epidemics of puerperal fever, is espe- 
cially so. When it has continued a few hours the pinched features and rapid 
sinking show that we have to deal with something more than an ordinary 
attack."^ 

' Deutsckes Archivfur klin. Med., Band iv. 

^ The following case, which occurred in my practice during the epidemic of puer- 
peral fever in 1881, may be adduced as an example: Mrs. I) , a primipara, was 

delivered by the forceps, after a tedious labor, at 9 p.m., April 6th. On the following 
morning her temperature, without the occurrence of a chill, had risen to 105J°, and her 
pulse varied between 125 and 134. She was in a critical state for several days with a 
temperature varying between 103° and 105j°, and without any local symptoms either 
of metritis or cellulitis, but finally recovered. The baby, healthy and vigorous at birth, 
had been allowed to obtain what nutriment it could from the breast, but -the nurse 
remarked that she "never saw a child sleep so much," and I gave very little attention 
to it, as my time was devoted wholly to the mother. On the 10th, when four days old, 
its sleepiness ceased, and it became constantly fretful, as from colic, and it refused 
to draw the nipple. Early in the morning of the 11th I was summoned to it, and 
was astonished at its altered appearance, its shrunken features, and its evidently dyiug 
state. Percussion upon the right side gave a flat resonance from the clavicle to the 
diaphragm, and there was some raeteorism in the abdomen. The thermometer intro- 
duced into the rectum showed no elevation of temperature, and no imusual heat of 
surface or cough had been noticed by the nurse. By active stimulation the infant lived 
till the middle of the afternoon. The autopsy revealed a sero-fibrinous exudation fill- 
ing the right pleural cavity, producing complete carnification of the lung, so that 
it resembled that of the foetal state, and soft patches or flakes of fibrin upon the 
lungs. By an oversight the peritoneum was not examined. Cases like this, of pleu- 
ritis in the new-born, produced, it is thought, by the wandering micrococci of the 
septic state, occur chiefly during epidemics of childbed fever. Some years ago I saw 
a new-born infant in one of the institutions, whose mother had puerperal fever, die in a 
similar manner, and the autopsy showed that the cause was peritonitis. The following 
example from Trousseau's clinical lecture on erysipelas of new-born infants will aid in 
understanding such cases. Speaking of Dr. P. Lorain, he says: "During the epidemic 
at the Maternite, where this able and laborious observer was resident pupil, he collected 
the information of which the following is a summary : Of 106 stillborn infants. 10 were 
found to have died from peritonitis, and 3 of the mothers of these 10 infants were car- 
ried off by puerperal fever after delivery. Of 193 infants born alive, 50 died of the 
very same affections which proved fatal to the lying-in women. The most frequent 
causes of death were peritonitis, numerous abscesses, purulent infection, piilegmonous 



TREATMENT. 725 

Pleurisy is also very severe, and ordinarily fatal, when it is caused by the 
entrance of some pathological product into the pleural cavity, as pus or decay- 
ing lung-suhstance. 

Treatment. — It will be proper, in considering the treatment, to describe 
that which is appropriate for each of the three stages into which writers 
have for convenience divided pleurisy : First, the stage preceding effusion ; 
secondly, that of effusion ; and thirdly, that of absorption and convalescence. 
In the beginning of the inflammation appropriate measures should be promptly 
employed for the purpose of reducing the inflammation and preventing or 
diminishing, so far as possible, the exudation that soon follows. The abstrac- 
tion of blood is now properly discarded in the treatment of most inflammations 
of infancy and childhood, but in certain cases of pleurisy occurring in robust 
children over the age of four or five, or even three years, the early and judi- 
cious employment of one or two leeches diminishes the pain and temperature, 
and apparently also, to a certain extent, the inflammation. But it may be 
stated as a rule that the loss of blood is not only not required, but is inju- 
rious, in all secondary pleurisies, and in the primary form after exudation has 
occurred. It is injurious in all forms of pleurisy in pallid and cachectic 
children, and therefore in a large proportion of the cases occurring in the 
tenement-houses and institutions of the cities. The flow of blood from the 
bites if leeches are employed should ordinarily be arrested after two or three 
hours, but if slight it may continue longer in vigorous children of eight or 
ten years. 

At the first visit of the physician an emollient and slightly irritating 
poultice should be ordered, enveloping the entire chest, to be constantly 
worn, except as it is temporarily removed during the application of the leech 
and the subsequent flow of blood. The poultice should be so mildly irritat- 
ing that it causes constant redness of the skin without pain, and it should 
not be removed except when a fresh poultice is prepared to replace it. Thus 
employed, it produces constant dilation of the capillaries of the skin, and by 
the fluxion caused diminishes the engorgement of the capillaries of the costal 
pleura. A poultice of common mustard, with flaxseed in powder, one part to 
sixteen, between two pieces of muslin, and so wet that it moistens the hand 
in holding it, produces this efi'ect. Applied morning and evening, it can be 
constantly worn without complaint of pain produced by its irritating action. 
For infants under the age of eight months I prefer the use of plain flaxseed, 
with camphorated oil smeared upon its under surface. The oil may be 
applied several times daily, while the morning and evening application of the 
poultice is sufl^icient. Spongiopilin or compresses of flannel wrung out of 
hot water and covered with oil-silk meet the indication, and possess the 
advantage of being lighter and cleaner and more readily applied than the 
poultice. Redness may be produced by applying under the spongiopilin a 
single thickness of muslin soaked with camphorated oil, or for children of a 
more advanced age with camphorated oil and one-fourth part of turpentine. 
Vesication, formerly much employed, has properly nearly fallen into dis- 
use in the treatment of the pleurisy of children. While it is liable to 
increase the sufi'ering, it has apparently no tendency to diminish the inflam- 

swellings, erysipelas, gangrene of the limbs, putrid infection, or some other remark- 
able septic condition." .... "Mother and child then are subject to the same morbific 
influence." Farther on Trousseau says of the infant affected by this puerperal poison : 
"It will cry incessantly from pain. A state of restlessness will be succeeded by col- . 
lapse, which will close the scene on the fifth, sixth, or seventh day. On examining the 
body after death pus will be found in tlie cellular tissue, sometimes suppurative pleurisy, 
more frequently phlebitis of the umbilical vein or of the vena porta, or peritonitis." 
An interesting incidental fact shown by these statistics is that the cause of this puer- 
peral disease of the new-born is sometimes operative in the foetal state. 



726 PLEURISY. 

mation in whichever stage employed, and there is no certainty that it stimu- 
lates the absorbents and expedites the removal of the liquid, according to the 
old theory. A case is reported in the practice of one of the New York phy- 
sicians in which a blister had been applied when the inflammation was still 
active, and at the autopsy the portion of the costal pleura which lay directly 
underneath the surface that had been vesicated was covered by a thicker 
fibrinous exudation than that upon the contiguous surface. The increased 
afflux of blood caused by the blister had, to appearance, extended to the 
costal pleura and increased the pleurisy. The application of cold bandages 
around the chest, which is recommended by some, seems to aggravate the 
cough in certain patients, and does not ordinarily give the relief of moist and 
warm applications. 

Internal Remedies. — The indications are to employ such medicines as 
diminish the frequent action of the heart, and thus retard in a measure the 
flow of blood to the pleura, and such as diminish the pain and frequency of 
the cough, which by increasing the friction of the pleural surfaces tends to 
increase the inflammation. For robust 'children over the age of three years 
in the first stage of primary pleurisy the tincture of aconite may be pre- 
scribed, half a drop for a patient of three years, and one drop for one of six 
years, every third hour for two or three days, or until the required eff'ect be 
produced upon the pulse, when it should be discontinued. It is, as a rule, 
too depressing for younger patients. Digitalis is a better and safer remedy 
ibr children under the age of three years for all secondary pleurisies and for 
all cachectic cases. Benefit results from continuing the use of digitalis in 
the stage of exudation, when aconite would be inadmissible. A child of two 
years can take two drops of the ofiicinal tincture, and one of five years four 
drops, every two or three hours. 

Antipyrine is an efl'ectual antipyretic. One or two doses reduce tempera- 
ture two or three degrees. It therefore promises to" be a useful remedy in 
the first stage of pleuritis as well as in other acute diseases, when the tem- 
perature is so high as to involve danger. It is not a tonic, and it seems to 
impair the digestive function. It is therefore most useful in those diseases 
which are not attended by any marked prostration, but in which the fever, 
from its intensity, exhausts the strength. If, therefore, in the commence- 
ment of pleurisy the temperature rises above 103°, it may properly be pre- 
scribed in doses of four grains to a child of five years, and be repeated, if 
necessary, in three hours. It is soluble in water, and it may be employed 
as an enema if the stomach be irritable. Phenacetin or antifebrin may be 
employed as a substitute for antipyrine. 

The use of quinia is suggested, since it is an antipyretic and tonic, but in 
my practice it has been much less useful in pleurisy than in pneumonia. 
This agent, in whatever form given, does not appear to exert any notable 
controlling eff'ect either on the fever or gravity of pleurisy. Nevertheless, I 
have often employed it, especially in secondary pleurisies, with or without 
digitalis, and it probably does some good as a tonic. The salts of quinia, as 
ordinarily given in solution to young children, are frequently vomited. When 
vomited, a soluble salt, as the bisulphate, may be given as a suppository, or 
Squibb's oleate of quinia may be employed by inunction. I should, however, 
add that, though I have used inunctions of the oleate in pleurisy during the 
last year, ten grains of the alkaloid at a time, I have not seen any marked 
beneficial eff'ect. To meet the second indication in the treatment of the first 
stage— namely, to relieve the pain and restlessness and to diminish the cough, 
so that there is less friction of the pleural surfaces — our chief reliance must 
be on hyoscyamus or one of the opiate preparations. The following formula? 
will be found useful : 



TREATMENT. 727 

R. Tinct. opii deodorat., gtt. xx; 

Tinct. digitalis, gtt. xl ; 

Syr. pruni virginiani, ,^j ; 

Aquse, 5Jss. Misce. 

Dose: One teaspoonfnl (one drachm) every three hours for an infant of eighteen' 
months. The tincture of hyoscyamus may be employed in place of the opiate in 
double the dose. 

For a child of three years : 

R. Tinct. ipecac, comp. 

(Squibb's liquid Dover's powder), 
Tinct. digitalis, da. gtt. xxxij ; 

Syr. pruni virginiani, ^ij. Misce. 

Dose : One teaspoonful every two or three hours. 

For a robust child of eight years with primary pleurisy : 

R. Morph. sulphat, gr. jl 

Tine. rad. aconit., gtt. xx ; 

Syr. pruni virginiani, Jijss. Misce, 
Dose: One teaspoonful every three hours. 

The diet in the first stage should consist of milk and farinaceous food, 
given liberally. The meat teas or the expressed juice of meat may be added, 
and in secondary pleurisies, as after scarlet fever, it is often proper to give a 
moderate amount of alcoholic stimulants from the first. 

Second Stage. — Measures employed in the first stage have been designed 
to diminish the inflammation and relieve suffering. The duty of the physician 
in the treatment of the second stage is chiefly to aid in the removal of the 
inflammatory product, and prevent, so far as possible, its further formation. 
If this be sero-fibrinous and its quantity be small, so as to fill only the lower 
portion of the cavity, little aid maybe needed from therapeutics; but a larger 
effusion, compressing the lung and displacing the heart, requires medicinal 
and often surgical measures. The recommendations of Niemeyer, that the 
patient's food contain little liquid and that his drinks be restricted as a means 
of increasing absorption from the pleural surface, is not applicable to young 
children, whose diet must of necessity be largely liquid, and that of infants 
chiefly milk. 

Attempts to stimulate the absorbents by external treatment of the chest 
are of doubtful efiicacy, whether by the application of small blisters, can- 
tharidal collodion, the iodine ointment or tincture, or a stimulating liniment. 
The common practice of treating glandular swellings by iodine applications 
suggests their use for pleuritic effusions, and of the agents employed locally 
to hasten absorption they are probably the best, but they should not be used 
so often or in such quantity as to cause pain or restlessness from their irri- 
tating effect. The following ointment may be used : 

R. Potas. iodidi, ,^ij ; 

Lanolin, ^ij. Misce. 

To be rubbed freely over the side of the chest which is the seat of the sero-fibrinous 
exudation three or four times daily. 

It is an established principle in therapeutics that the removal of a serous 
liquid in either of the larger cavities of the body is hastened by such rem- 
edies as produce an abundant liquid secretion or transudation from any of the 
organs or surfaces. Hence in the treatment of pleuritic effusions those med- 



728 PLEURISY. 

icines wliich act on the skin, causing diaphoresis, upon the intestines, causing 
watery stools, and upon the kidneys, causing diuresis, are at once suggested 
as most likely to be efficacious. But sudorifics, though useful for dropsies 
having a renal origin, have not been much used of late years for the removal 
of exudations in the pleural cavity, experience having shown that they are 
inadequate for this purpose. Recently, however, the discovery of a very 
active agent of this class, jaborandi, has revived in a measure the sudorific 
treatment of the second stage, so that in the National Dispensatory of Stille 
and Maisch this diaphoretic is one of the recommended remedies. But the 
heart, crippled in its action by the pressure of the liquid, badly tolerates 
agents of a depressing nature, and jaborandi, or its active principle pilocarpine, 
exerts a weakening effect on this organ. It therefore should be used with 
caution in this disease. It is probably best in most instances not to employ 
it, inasmuch as we possess other and efficient remedies. 

The fact that sero-fibrinous exudations have been known to diminish rap- 
idly during attacks of diarrhoea suggests the use of purgatives ; but, although 
an open state of the bowels, as two or three daily stools, aids in absorption, 
free purgation is badly borne by young or feeble children, as it reduces the 
strength, and therefore is not to be recommended as a therapeutic measure. 
Moreover, there is not the need of employing severe or exhausting medicines 
for the removal of the liquid which existed in former times, since we are able 
to accomplish this quickly, easily, and safely by the excellent aspirating 
instruments now in common use. 

Diuretics, on the other hand, are apparently more useful, while they are 
less exhausting, than sudorifics or cathartics. Digitalis, combined with the 
citrate or acetate of potassium, has stood the test of experience, and is now 
more widely used than any other agent of this class. Being both a diuretic 
and heart-tonic, it possesses properties which render it especially serviceable 
in the treatment of pleuritic effusions. The following is a useful prescription 
for a child of five years : 

R. Potassii acetatis, .^ij ; 

Infus. digitalis, ^^iij. Misce. 

Give one teaspoonful every three hours. 

It is a matter of observation that absorption occurs more rapidly, and a 
sero-fibrinous is less likely to become a purulent effusion, if the bodily con- 
dition be good. Hence tonics, especially the bitter vegetables, are sometimes 
useful, and a diuretic in combination with a tonic, as the acetate of potassium 
in decoction of cinchona, may often be prescribed with advantage. 

Still, however judicious the treatment, hygienic and medicinal, many 
cases require surgical interference, and the number of such is larger in the 
city than in the country, and in tenement-houses than in the better walks of 
life, since the cachexia so common in city children increases the liability to 
purulent exudations. 

Thoracentesis. — The indications for the operation are the following : 

1st. Dyspnoea due to the presence of the liquid, whether it be sero- 
fibrinous, purulent, or hemorrhagic. Usually when dyspnoea occurs the 
pleural cavity is full, and if there be parenchymatous disease of either lung 
a moderate quantity of liquid may cause such embarrassment of respiration 
that thoracentesis is indicated. 

2d. A flat percussion sound over the entire affected side, with displace- 
ment of the heart, even if there be no present dyspnoea, is also an indication 
for the operation, for dyspnoea may occur suddenly with other alarming symp- 
toms between the visits of the physician. Moreover, experience has shown 



TREATMENT. 729 

that absorption from a distended pleural cavity is very tardy, in consequence 
of compression of the absorbents, whereas if a portion of the liquid be 
removed absorption of the remainder is more rapid. The patient with full 
pleural cavity and lung totally compressed lies on the affected side, and is 
usually uncomfortable in any other position, and the withdrawal of a portion 
of the liquid — as, for example, one half — the operation being discontinued 
when the patient begins to cough or evince distress, produces no ill-effect and 
increases the comfort. 

3d. A moderate effusion, without material decrease in quantity after some 
weeks of observation, also indicates the need of surgical interference, since 
long compression of a lung involves risks. There is danger that catarrhal 
ending in cheesy pneumonia and tubercles may occur in a lung whose func- 
tion is long suspended ; besides, the longer compression has existed the more 
tardy, difficult, and incomplete will be the inflation when the liquid is removed, 
on account of the altered state of the alveoli and the presence of fibrinous 
bands over the lung. Thus, in a case recently under observation only partial 
inflation of the lung occurred after letting out the liquid, so that the ribs and 
shoulder on the affected side are permanently depressed and unequivocal 
symptoms of tuberculosis are now present. 

4th. If the inflammation extend to the pericardium, so as to cripple the 
heart's action, or if there be any serious pre-existing heart disease, the liquid, 
even in moderate quantity, may by pressure so embarrass and retard the 
heart's action that its cavities are not properly filled, so that passive conges- 
tion of certain organs and dangerous anaemia of others, especially of the 
brain, may result. Under such circumstances an early performance of tho- 
racentesis is indicated. 

5th. Empyema. — The presence of pus in the pleural cavity affords in itself, 
in a large proportion of cases, sufficient indication of the need of thoracente- 
sis. In recent cases with only moderate constitutional disturbance and embar- 
rassment of respiration, if we ascertain by the hypodermic syringe that the 
liquid is only slightly clouded by leucocytes, surgical interference may be 
postponed while the acute inflammation is treated. Thus, in case of an 
infant of two months thin pus was withdrawn on the fourth day of acute 
pleuritis, and, although thoracentesis was early performed, it appeared prob- 
able, from the subsequent course of the case, that it would have been as well 
had the operation been deferred. If spontaneous evacuations of pus have 
occurred through one of the intercostal spaces, producing a fistula from 
which there is a daily oozing, or if it be probable, from the symptoms and 
signs, that pus is escaping from the pleural cavity into a bronchial tube, and 
is being gradually expectorated — a mode of cure which, as I have elsewhere 
stated, is not infrequent in children — thoracentesis may be deferred. In the 
case of an infant aged six months recently under treatment for empyema of 
the left side we removed four ounces of pus and washed out the pleural 
cavity. The opening having closed, and the physical signs indicating the 
reaccumulation of a considerable quantity of liquid, we were preparing for a 
second operation when the parents and nurse called our attention to the fact 
that there were occasional severe attacks of coughins;, during which the 
breath presented a very decidedly purulent odor. Although there was no 
external expectoration, as the sputum was swallowed, thoracentesis was post- 
poned, and the result justified the decision, for the patient gradually conva- 
lesced. Except under circumstances like the above, empyema, when clearly 
diagnosticated by the employment of the hypodermic syringe, should be 
promptly treated by evacuation of the pus. 

Lutruments to he Used; and Mode of Operating. — Ingenious instruments 
for tapping the chest have been invented by Dr. Chadbourne of New York, 



730 PLEURISY. 

Dr. A. M. Phelps of Chateaugay, Franklin co., N. Y., and others, which by 
India-rubber packing totally exclude air while the operation is performed 
with facility and little pain. That devised by Dr. Chadbourne has a canula 
with two arms, one for attachment by means of tubing to the exhausting 
receiver, and the other is designed to facilitate irrigation of the pleural 
cavity. 

Phelps's apparatus has a third tube, entering the bottle through the stop- 
ple, and a glass tube passes from the stopple to nearly the bottom of the bot- 
tle. With this apparatus, by reversing the movement of the syringe, the 
liquid can be withdrawn from the chest, the bottle emptied of it, the water 
used for irrigation be conveyed into the bottle, from the bottle to the chest, 
and back into the bottle, without changing the position of the bottle or 
removing the stopple. I would suggest the use of the trocar and canula 
instead of the sliding aspirator point, which plays outside the canula, as 
an improvement in this instrument. 

The instrument which I have been in the habit of employing is of sim- 
pler construction. The canula is about the size of the smallest needle of 
Dieulafoy's aspirator — the proper size, in my opinion, for thoracentesis for 
both sero-fibrinous and purulent exudations. I greatly prefer the use of the 
exhausting-bottle rather than the exhausting-pump without the bottle, as it 
is more convenient and produces greater suction from its greater size. The 
canula is provided with an arm which connects it by tubing with the exhaust- 
ing-bottle. Beyond this arm the body of the canula, suiSciently expanded to 
contain India-rubber packing, extends about one and a half inches and is 
provided with a stopcock. Through this packing the trocar is introduced, 
and after the puncture it is withdrawn to the stopcock, which is then 
turned to prevent the admission of air. Then the obturator is introduced 
in place of the trocar, so as to remove any obstruction which may enter the 
canula. 

The tubing which extends from the arm of the canula to the bottle 
should be firm, with a somewhat larger bore than that of the canula, and 
its point of attachment to the bottle should also be provided with a stop- 
cock. A short glass tube introduced into this tubing near the canula is 
convenient for noticing the character of the fluid, which, if it be thick pus, 
may flow with difiiculty and not reach the bottle. A bottle of sufficient 
capacity to hold two quarts obviously produces more suction power than one 
of less size, and is therefore preferable for certain cases, and its sides should 
be marked to indicate ounces and drachms. The tube which connects the 
canula with the bottle enters through the stopple, and proceeding from the 
stopple is another tube similar to the first, to which the syringe is attached. 
The syringe has two points for attachment to the tube and a double action 
in its interior, so that attached by one point it exhausts the air from the 
bottle, and attached by the other point it condenses air in the bottle. The 
stopcock between the canula and the bottle should always be closed when 
the syringe is used, whether for exhaustion or condensing. It is very 
important that this should be constantly borne in mind when working 
the syringe, or air may be thrown into the pleural cavity and much harm 
done. 

Mode of Opprating for Sero-fihrinous Exw^atiovs. — In the following 
remarks I shall state what I consider the best method for performing 
thoracentesis, having formed my opinion from the cases which I have 
witnessed and been able to follow in institutions and in family practice. 
A mode of treatment which may be safe and proper for the adult is not 
always the best for the child, and, as there are different opinions and diff"er- 
ent modes of procedure, and as many who are familiar with adult cases 



TREATMENT. 731 

recommend similar treatment for the child to that which they have 
emplo3'ed with success for the older and more robust cases, I shall 
advise the abandonment of certain measures which are in common use 
and the substitution of others. The hypodermic syringe should be first 
used at the point where it is proposed to perform the operation, the dis- 
infected needle being inserted about one inch, for I hold it unjustifiable to 
tap the chest without first ascertaining that there are no adhesions at 
the site selected for puncture, and at the same time ascertaining the 
character of the liquid. Incision of the skin with the knife and spraying 
the surface with ether are not required as preliminary treatment, since the 
puncture is quickly and easily performed with a small trocar and with very 
little pain. The rule is established by many observations that the operation 
should be performed in or near the vertical line passing through the angle of 
the scapula and between the eighth and ninth ribs or one of the adjacent inter- 
costal spaces. I have elsewhere stated that a point a little external to this 
line is preferable, as the lung is less liable to be injured. The instrument 
should obviously be inserted no farther than will be sufficient to reach the 
liquid, and, since from measurements which I have made the thickness of 
the thoracic wall in rather fleshy children is about half an inch, penetration 
to the depth of one inch will ordinarily be sufficient to pass the fibrinous 
layer. We are liable to puncture more deeply than is necessary without 
some safeguard, and incur the risk of wounding the lung. India-rubber 
tubing may cover the instrument to within one inch of the end, or a cord 
may be tied snugly around the instrument at one inch from the tip. The 
sensation communicated to the fingers will, however, be the best guide to the 
careful operator as regards the exact depth to which the instrument should 
be carried. The trocar should now be withdrawn, the obturator introduced 
in its place, the air exhausted from the bottle, and then the stopcock turned 
to allow the liquid to escape. 

It should flow slowly, as it probably will through so small a canula, but 
the flow can be regulated by the stopcock. The quantity to be removed 
depends upon the age and condition of the child, the size of the cavity, and 
the quantity of the liquid, but if the patient begin to cough or feel uncom- 
fortable after the removal of one-half, or even one-third of the liquid, the 
<3anula should be withdrawn. The sensation of insufficient breath is no 
longer experienced, and the remaining liquid is progressively absorbed. This 
operation is one of the easiest in surgery, while, with the precautions men- 
tioned above, no ill eff"ect need be apprehended. One operation is, in most 
instances, all that is required, though if need be it can be repeated after some 
days, and it is very seldom that the lung does not fully expand to fill the 
chest if the operation be performed at the proper time. 

Mode of Operating for Empyema. — It will aid in understanding this part 
of our subject to remember that all pleuritic exudations contain pus-cells, and 
that the on\j anatomical diff"erence between sero-fibrinous exudations and 
empyema is in the proportion of these cells. There is, therefore, no fixed 
and definite boundary-line between the two kinds of exudation. The term 
■'"empyema" is, as all know, applied by common usage to the liquid when it 
contains so many leucocytes or pus-cells that a turbid appearance is imparted 
to it. Absorption is slow and difficult or impossible if the liquid contain a 
large amount of solid ingredients — to wit, fibrin and pus-cells — while liquid 
containing only a small proportion of these constituents more readily enters 
the absorbents. In other words, thin pus may be absorbed and removed from 
the system by natural methods, or by the same instrument and operation 
which we have recommended for sero-fibrinous exudations, while a thick 
liquid adherent to the pleura or sinking heavily in dependent portions of the 



732 PLEURISY. 

cavity disappears very slowly, losing by absorption only a little of the liquor 
puris, while the bulk of it cannot be absorbed, so that the only relief is by 
evacuation through an opening. Often in practice, after the acute symptoms 
of an empyema have in a measure abated, the physical signs indicate some 
diminution of liquid in successive weeks, but further removal soon comes to 
a standstill and the resources of surgery must be tried. 

The same small trocar and canula, or a little larger, should be used for 
tapping the chest of an empyemic child which we have recommended for 
sero-fibrinous exudation and with the same precautions. If the liquid be thin 
and but slightly turbid, if it be but little removed from sero-fibrin in its cha- 
racter, it will flow through the canula, even if it be necessary to use the 
obturator often to remove obstructions. Having withdrawn all the liquid 
which will flow through the opening, unless severe coughing or some unpleas- 
ant symptom occur, which is an indication to discontinue the withdrawal, the 
instrument is removed and the aperture may be closed with adhesive plaster. 
In exceptional instances, if the pus be thin and the pus-cells few in propor- 
tion to the amount of serum, one aspiration may be sufiicient to efl"ect a 
cure : but usually the cavity refills. If the pus be thick, it will almost 
inevitably refill, and it is better to make a free incision with a bistoury at 
once. If the pus be thin and the cavity after aspiration refill in a few weeks, 
free incision is preferable to a second aspiration, for as a rule the lung should 
not be compressed by pus more than four to six weeks, for by longer com- 
pression it might be seriously injured. 

Therefore if the chest refill after one or at most two aspirations, an incision 
should be made with the knife at the same point as that selected for aspiration — 
that is, between the eighth and ninth ribs and in the line passing perpendicularly 
through the lower angle of the scapula. An incision should be made with a 
sharp-pointed bistoury a little nearer the ninth than the eighth rib, sufficiently 
large to admit the blunt-pointed bistoury, and with this the incision should 
be extended to the distance of one-third to one-half inch, which will allow 
the pus to flow out freely. The opening should then be covered by oakum 
confined by long strips of adhesive plaster. Pus may or may not continue to 
flow into the oakum. If it do not, the opening will close, if left to itself, 
within two or three days. No tent or drainage-tube is employed, for reasons, 
to be mentioned hereafter. The physician should return after twelve or 
twenty-four hours, not later, and should introduce through the opening the 
ordinary gum-elastic male catheter, warmed so as to be flexible and strongly 
bent at its middle. The point should be directed to the bottom of the cavity. 
Perhaps the soft rubber catheter might be preferable, but I have never used 
it, being satisfied with the other. The catheter should be attached by tubing 
to the exhausting-syringe or bottle, and any pus in the depending portions of 
the cavity will be readily removed. I have generally at this visit removed 
from the bottom of the cavity two or three ounces, sometimes very thick, and 
such as would not readily flow from the opening. Every day or twice daily 
the operation should be repeated ; which will, I think, more eft'ectually remove 
the pus than washing out the cavity, and the opening cannot close. This 
operation detains the physician only a few moments. The catheter should be 
a No. X., and it is the best possible probe. By the close of the first week 
the opening becomes fistulous. 

After each removal of the pus long strips of adhesive plaster firmly 
applied over the ribs, from the sternal region downward and backward,^ 
facilitate approximation of the pleural surfaces and obliteration of the cavity. 
During convalescence the patient, if old enough, should be directed to make 
full inspirations, which serve to expand the lungs. 



TREATMENT. 733 

That so simple and important an operation as thoracentesis should have 
been known and practised by the ancients — even, it is said, by Hippocrates — 
and have fallen into disuse till it was revived in our own times by Bowditch 
and Trousseau seems remarkable. This was probably in part due to the bad 
instruments employed, and in part to the fact that in olden times the opera- 
tion was performed in the anterior walls of the chest, where adhesions are 
frequently present. But there are certain accidents and unfavorable results 
of the operation which may be profitably considered, since they can nearly 
always be avoided : 

1st. The Admission of Air into the Pleural Cavity. — This is unnecessary 
and can be avoided ] but those who have often witnessed the operation as 
ordinarily performed have remarked the fact that the admission of more or 
less air is common. 

The entrance of a certain amount of air into a serous cavity when the 
serous membrance is in its normal state does not appear to be productive of 
harm with ordinary precautions as regards temperature, etc., as in ovariotomy, 
in which air is admitted into the largest serous cavity in the body ; and the 
moderate admission of air into the pleural cavity when the pleura is healthy 
does not, as a rule, produce any ill effect. Thus, a case is related of a man 
who sufiered from heart disease, and was led to think that the pressure of a, 
small amount of air internally might be substituted for external pressure, 
which always gave relief.^ He was his own instrument-maker and operator. 
He constructed a small tube about as slender as a common pin, to which a 
bladder was attached filled with air. The point of this was thrust through 
an intercostal space till it penetrated the pleural cavity, and air was made 
to enter by compressing the bladder. Relief always followed and the 
patient's health improved. This treatment was continued two or three years. 
Dr. Lizars, who was present at the meeting of the medical society before 
which this case was related, stated that he had performed a similar operation 
on four or five patients affected with aneurisms, with some apparent benefit 
and in no case with injury. 

But the condition is very different if there be inflammatory products in 
the cavity. It is a fact known to all observers that animal liquids withdrawn 
from the circulation and escaped from the vessels through injury or disease 
remain in a closed cavity for a lengthened period without putrefactive change 
— as, for example, a clot of blood under the scalp or pericranium of a new- 
born infant — but if air be admitted it becomes offensive within a few hours. 
The admission of air into the pleural cavity which contains exuded products 
undoubtedly promotes putrefactive changes in the latter, and the admission 
of even a small amount of air, containing, as it does, micro-organisms which 
multiply rapidly in the animal fluids, and which appear to be the active 
agents in putrefaction, sufl&ces to convert sero-fibrin or laudable pus into an 
offensive, irritating, and poisonous liquid, which increases the constitutional 
disturbance and the gravity of the disease. 

Air in the pleural cavity, in proportion to its quantity, also tends to pre- 
vent the approximation to each other of the pleural surfaces and the oblitera- 
tion of the cavity, which is required in all empyemic cases, since this is the 
mode of cure. Obviously, the entrance of air does less harm if there be 
a fistulous opening and pus escape as soon as it forms than in a closed cavity, 
but it should in all instances be avoided, as never beneficial and likely to do 
harm in the manner indicated. It is never a necessary accident of thoracen- 
tesis, since it can be avoided by the use of proper instruments provided with 
India-rubber packing and stopcocks. There can be no doubt, also, that the 
point of the aspirator has often so pricked and torn the lung that air has 

^ London Lancet, January 15, 1831. 



734 PLEURISY. 

entered the cavity from this organ — a result avoided by judiciously using the 
trocar and canula. 

2d. Injury to the Lung hy the Surgical Instruments Used. — The lung is 
sometimes injured by the point of the hypodermic needle employed for 
diagnosis. Cases are reported in the hospitals of New York of the break- 
ing off and loss of the needle in the lung from sudden and strong move- 
ment of this organ, as in coughing. The most severe injury is, however, 
commonly produced by the aspirator needle, and some very serious cases 
of this accident have occurred in which the needle so pierced and tore 
the lung that not only air escaped from it, but also a considerable quantity 
of blood. It is obvious that the danger of injuring the lung is greater in 
recent than in chronic cases, and greater in sero-fibrinous than in purulent 
pleuritis, for a thickened, infiltrated, and firm pleura affords protection to the 
lung. It is very difficult to avoid injuring this organ if suction be made and 
the liquid be withdrawn with the unguarded point of the aspirator needle 
projecting into the chest. The removal of the liquid necessitates the 
impinging of the lung upon the point of the instrument even if it be held 
very obliquely, and in recent cases, when there is a little thickening and 
infiltration of the pleura, the surface of this organ may be pricked or torn 
sufficiently to allow air to escape and hemorrhage occur, when the operator 
who holds the needle can scarcely believe that such an accident were possi- 
ble, so slight has been the sensation communicated to the fingers. Thus, 
thoracentesis was performed on an infant of two months who had severe 
empyema of short duration. The instrument was held by myself obliquely, 
and it entered the pleural cavity only a short distance, and yet the lung was 
injured in three places, from which it was probable, from the signs and 
symptoms, that air had escaped. The specimen showing the injury was 
exhibited to the Pathological Society in 1879. Obviously, to prevent this 
injury aspiration should be performed through the covered needle, as that of 
Phelps's or Potain's, or the trocar, which I have recommended above and 
prefer. I must here repeat what has been stated above, not to plunge the 
trocar to a greater depth than is needed, which is about one inch. The end 
of the canula may also injure the lung if it be pressed in too deeply, since it 
is necessarily rather sharp from its small size. 

3d. WasMng out the Pleural Cavity. — Since the aspirator has come into 
general use, it is the common practice to wash out the pleural cavity with 
carbolized water in the treatment of empyema. The proportion of carbolic 
acid to water commonly employed is about one part to eighty, and at a tem- 
perature of 100°. From a discussion at the meeting of the New York Sur- 
gical Society, Oct. 12, 1880, it appears that the use of carbolized water 
involves risk of carbolic-acid poisoning in case the liquid be only partially 
removed after it is thrown into the pleural cavity ; and the late Prof. Erskine 
Mason was in the habit of employing salicylic acid, one part to the hundred 
of water, in place of carbolic acid, since it possesses all the advantages with, 
none of the possible risks of the latter. He stated that it promptly deodor- 
izes fetid pus even in the proportion of one part to two hundred. The use 
of carbolic acid would probably be entirely safe if the liquid were removed 
immediately after washing the cavity, but for some reason this is not always 
possible. In case of an infant with empyema under treatment by Drs. Lock- 
row, Billington, and myself, after removing the pus by trocar and canula 
attached to the exhausting-bottle, and once washing out the pleural cav- 
ity, the liquid was thrown in a second time, giij, into the left pleural cavity of 
an infant of five months, but not a drop of it could be removed. There 
was, however, no symptom which we could refer to the carbolic acid. In 
view of these facts and the possible danger of carbolic-acid poisoning, the 



TREATMENT. 735 

use of salicylic acid appears to be preferable, at least for children, who are 
less able to resist the action of poisonous agents than adults. 

In this connection I must state my conviction that washing out the pleu- 
ral cavity is unnecessary if empyema be treated as recommended above, and 
it may be injurious. But it is proper treatment when the pus has under- 
gone decomposition, is oifensive to the smell, and therefore poisonous. If it 
be putrid, its immediate disinfection as well as removal from the pleural 
cavity appears to be clearly indicated, but in the common form of empyema, 
as the pus escapes through the opening which has been made and the suppu- 
rative cavity becomes smaller, adhesions of the pulmonary and costal sur- 
faces occur, which the injection of water may tear up and destroy, and thus 
the obliteration of the cavity is retarded. Letting out the pus and approx- 
imation of the pleural surfaces to each other are the indications as regards 
surgical measures. Besides, washing out the pleural cavity is not devoid of 
danger. Alarming symptoms may be developed unexpectedly and rapidly, 
even when the operation is slowly and cautiously performed. The infant of 
five months with empyema whose case I have alluded to furnished a striking 
example of this. Four ounces of pus had been removed through a small 
canula from the left pleural cavity, and without removing the canula the. 
cavity had been once washed out. It was proposed to repeat the washing, 
as the infant had thus far tolerated the operation and was in an unusually 
favorable state for a case of empyema. The patient was in a semi-erect 
position, and three ounces of water at a temperature of 100° had entered 
the cavity from the inverted bottle, when he began to cough, fretted, and 
became very restless. Immediately, Dr. Lockrow applied the suction-point 
of the syringe to the tubing, and attempted to withdraw the liquid, but 
with no result. The patient's face assumed a deadly pallor, he frothed at 
the mouth, his lips were compressed, and breathing ceased. He was to all 
appearances dead. He was immediately placed upon the back by Dr. Billing- 
ton, and by prompt resort to artificial respiration the terrible suspense was 
soon ended by the gasps of the child and the return in a few moments of 
consciousness and normal respiration. It seemed to me that this untoward 
accident was due to the flow of water against the heart, so that it prevented 
full dilatation of its cavities, and consequently diminished the flow of blood 
into the aorta and produced anaemia of the brain. Lichtenstern says : " Va- 
rious causes which sometimes quite interrupt or impede the flow of blood to 
the left heart, such as severe paroxysms of coughing, vomiting, lifting heavy 
burdens, may give rise to a suddenly fatal anaemia of the left heart, and 
secondarily of the brain. The anaemia of the lungs or brain found in many 
cases is only of secondary importance. It frequently happens after thora- 
centesis with aspiration that an anaemia is produced in the partially distend- 
ed lung, and this may lead to death by asphyxia. In sudden death during, 
immediately, or a~ short time after thoracentesis by aspiration the cause is 
anaemia, either of the heart or brain. In cases in which severe syncope and 
sudden death are observed during the irrigation of the pleural cavity the 
cause is either direct mechanical concussion of the easily-exhausted heart 
by the stream of water thrown in, or shock." ^ 

4th. The Use of Tent and Drainage-tube in Empyema. — With due regard 
for the opinions of the experienced surgeons who employ and recommend the 
tent and drainage-tube, but whose observations have been largely upon adult 
cases of empyema, I cannot recommend their employment for children, unless 
perhaps the tent for a day or two after the incision ; but the tent is not neces- 
sary if the catheter be daily introduced in the manner which I have advised. 

^ Deuisches Archiv fur klin. Med., Band iv., 4 Heft. ; London Med. Record, Dec. 15, 
1880. 



736 pleurisy: 

The drainage-tube almost necessarily admits air during inspiration, but this 
is not the most serious objection to it. Cachectic children with poorly nour- 
ished tissues badly tolerate pressure upon an open wound by a hard substance. 
It is liable to cause ulceration and enlarge the opening, and continued pres- 
sure of the tube may cause periostitis upon the edge of the rib and necrosis. 
Scrofulous and feeble children are very prone to both caries and necrosis from 
€ven slight pressure or bruises upon the surface of the bone — a result to which 
adults are much less liable. In a paper published by Mr. W. Thomas^ on 
the treatment of empyema by resection of one or more ribs, 9 cases are 
detailed, in 3 of which necrosis had occurred from pressure, it is stated, of 
drainage-tubes, thus necessitating the removal of the diseased portion. Dur- 
ing the year 1881 a wasted empyemic infant was brought to one of the insti- 
tutions of this city for treatment. After letting out the pus a drainage-tube 
was introduced and secured. At the next visit ulceration had so enlarged 
the opening that a large amount of air entered the chest with a whistling 
noise at each inspiration, and was expelled during expiration, and necrosis of 
the portion of the rib against which the tube pressed had also occurred. Air 
was finally excluded by covering the opening with a cloth smeared on each 
side with a concentrated solution of gutta-percha in chloroform, but the case 
after some days ended fatally. The escape of the drainage-tube into the 
pleural cavity, which has occurred by breaking of the threads which secured 
it, is so rare an accident that it does not constitute an objection to the intro- 
duction of the tube ; but aspiration daily or twice daily through the catheter 
so completely removes the pus that drainage is not required, and the risk of 
injury by the pressure of the tube is therefore avoided. 

5th. I have witnessed in a few instances the burrowing of pus under the 
skin at the point where an incision had been made to let out the pus. This 
complication may lead to more or less ulceration or sloughing, and it greatly 
increases the danger of poisoning. But infiltration of pus will almost never 
occur if the incision be direct through the tissues, and not with the skin 
pushed to one side, so that it forms a covering or valve when it returns, as 
was once recommended in the books as a means of excluding air. But air 
does not enter the cavity through a direct opening if it be properly covered 
after the pus has escaped. Burrowing of pus and pyaemic poisoning there- 
from cannot then be regarded as an accident of the mode of operation which 
I have recommended. 

Bxsection of a Portion of One or More Ribs. — This operation has 
now been performed a considerable number of times in Europe and in this 
country, and, from the published accounts, certain cases have apparently 
recovered more rapidly in consequence. Thus in one case a fistulous open- 
ing, spontaneously established, had continued several months with little 
diminution in the discharge and very slow progress toward recovery, when 
by this operation, which produced a larger opening and a freer escape of pus 
and falling in of the chest-wall, so as to obliterate the cavity, the patient 
rapidly convalesced. 

The alleged benefit from the exsection, which consists in the removal of 
an inch or a little more of one or more ribs in or near the site for the uEual 
performance of thoracentesis, is, that there is a readier escape of pus and the 
facility for washing out the pleural cavity is increased, and the thoracic wall 
and lung are more readily approximated, so as to produce obliteration of 
the pleural cavity. The greatest benefit is claimed for it in those cases in 
which the intercostal spaces are small and the ribs lie close to each other. 

Without denying that certain cases have apparently been benefited by the 
operation, I must say that I have not yet met a case, either in family or hos- 

1 Birmingham Med. Bee, 1880, N. S. vol. iii. 



NERVOUS COUGH. 737 

pital practice, in which I could conscientiously recommend the operation, 
except where necrosis had occurred from a periostitis produced by the irri- 
tating property of the pus or the pressure of a drainage-tube. The gum- 
elastic catheter, introduced as recommended above, will pass through any 
intercostal space which I have yet observed, so as to allow free evacuation 
of the pus by suction, if it be not incapsulated by fibrinous bands, and allow 
also the free washing out of the pleural cavity if this be desired. 

There are also serious objections to the exsection in case of a child. The 
system, exhausted by suppurative inflammation, is in poor condition to tole- 
rate an operation of an}^ severity, and, although we are directed to preserve 
as far as possible the periosteum from injury by the knife, and be careful not 
to wound the intercostal vessels, there are necessarily more or less shock and 
hemorrhage and consequent danger of hastening the death of the patient. In 
one of the cases, that of an infant, reported by an advocate of the operation, 
it seems to me that death was largely attributable to the exsection. 

In order that exsection aid materially in the approximation of the lung 
and ribs, it is necessary to remove portions of two or more ribs, and the 
greater the operation the greater the risk. But what is needed is not depres- 
sion of the ribs, which may produce permanent deformity, but expansion of 
the lung, and this is promoted by the integrity and resiliency of the ribs. 



CHAPTER IX. 

NERVOUS COUGH. 

A NERVOUS cough sometimes occurs in children, especially between the 
ages of two or three and ten years. It may result from disease of the brain, 
from the second as well as first dentition, from some irritant in the intestines, 
as worms, and also from spinal irritation. Irritation in the external ear from 
the presence of a foreign substance excites a cough in some children. A 
similar fact is noticed by many adults — namely, that attempts to remove the 
wax from the ear by an instrument excites a cough. Occasionally there 
appears to be no local cause, but a state of anaemia or a highly developed 
nervous temperament, to which it seems proper to ascribe the cough. Occur- 
ring under these last circumstances, it corresponds with, and is sometimes 
accompanied by, functional disturbance in the action of the heart, as palpi- 
tation. 

A nervous cough is short, painless, and without expectoration. It usually 
attracts little attention at first, but from its long duration the friends finally 
become anxious lest it betoken some serious disease. At times it may nearly 
subside if the patient lead a quiet life and the general health improve, and 
there are periods of recrudescence if the opposite conditions obtain. It may 
have a spasmodic character, especially in times of mental excitement, but in 
a less degree than the cough of pertussis. If not properly treated it usually 
continues several weeks or months, disappearing as the general health and the 
tone of the nervous system improve. It is not in itself a serious disease, nor 
does it lead to any ailment or produce any injury of the respiratory organs, 
but it is an unpleasant malady, and is liable to be mistaken for incipient 
tuberculosis if it occur in one decidedly cachectic and belonging to a family 
predisposed to phthisis. 

Treatment. — If there be a local cause of the cough, measures calcu- 
47 



738 NERVOUS COUGH. 

lated to remove this, or at least to palliate its effects, are obviously required. 
Especially should constipation or any abnormality in the digestive function 
be corrected. But in many cases there is no apparent local ailment which 
produces the cough by its irritative action, and the remedial measures must 
then be twofold — to wit, first, those designed to .improve the general state ; 
and, secondly, those designed to relieve the cough. Such measures are also 
required in most cases in which there is a local cause, provided that the 
cough do not cease when treatment calculated to remove this cause has 
been employed. 

For constitutional treatment no remedy is so useful in ordinary cases as 
iron. The following example shows the benefit which may result from the 
use of this agent, since in this case it effected a cure without the aid of other 

measures : B , aged eleven years, pallid and of spare habit, but active 

and with good appetite, had been treated for this malady by different physi- 
cians but without improvement. His mother had died of tuberculosis, and 
some at least of the physicians believed that he was in the commencement 
of the same disease. Finally, he was placed under the care of the late 
Dr. Cammann, who, detecting the nature of the malady, wrote the follow- 
ing prescription : 

R. Ferri. subsulphat., .^ss ; 

Acid, nitric, f^ss ; 

Aq. destillat., f^ss. Misce. 

Dose: Three drops four times daily in sweetened water. 

The cough disappeared in a surprisingly short time. If the appetite be 
poor, the vegetable tonics are required in combination with iron. 

If the cough be frequent and troublesome, medicines which exert a direct 
controlling effect upon it are required in addition to the treatment employed 
to improve the general state. For this purpose no remedy is so useful as the 
bromides, employed alone or in combination with belladonna. If there be no 
decided anaemia, and no local cause of the cough, the bromides and belladonna 
usually effect a cure without the employment of constitutional measures, or if 
the case seem to require iron it may be given in the interval. The following 
is the prescription for a child of three years : 

R. Tinct. belladonnse, gtt. xxxij ; 

Potas. bromid., 
Ammon. bromid., da. 3J ; 
Syr. siraplic, ^ij. Misce. 

Dose : One teaspoonful three times daily. 

In 1871, 1 was asked to prescribe for a German boy, aged eight and a half 
years, who had a cough of this kind of two months' duration, which latterly 
had been frequent and annoying. Within a week he was entirely relieved 
without other remedy by the employment of tincture of belladonna, drops v, 
and bromide of ammonium, gr. v, twice daily, Outdoor exercise or country 
residence and other regimenal measures which improve the general health 
are useful in ordinary cases. 



SECTION" III. 
DISEASES OF THE DiaESTIVE APPARATUS. 



CHAPTER I. 

SIMPLE STOMATITIS, ULCEROUS STOMATITIS, FOLLICULAR 

STOMATITIS. 

Diseases of the digestive system are very frequent in infancy and child- 
hood. They are for the most part readily recognized, and are more easily and 
quickly controlled by therapeutic agents, if rightly applied, than are the dis- 
eases of any other system. If misunderstood and improperly treated, they 
may, even when mild and very manageable in their commencement, become 
chronic and obstinate, or even fatal, or they may lead to other and more dan- 
gerous diseases. It is necessary, then, that the physician should understand 
thoroughly the pathology as well as therapeutics of the digestive system, that 
he may make timely and correct use of the required remedies. 

The diseases of the buccal cavity in early life are for the most part inflam- 
matory, one of the most interesting of which — to wit, sprue or thrush — we 
have already treated of among the diseases of the newly-born. The mildest 
of these diseases is that known as 

Simple or Catarrhal Stomatitis. 

This form of catarrh occurs usually before the completion of the first 
dentition, and it is most frequent under the age of one year. Giving rise in 
itself to no severe symptoms, and often being connected with other grave 
and dangerous maladies, it is, doubtless, in many cases overlooked. It is 
sometimes confined to a portion of the buccal surface or is more intense in 
one part than in another. In other cases the catarrh is uniform or nearly so, 
afi"ecting the entire cavity of the mouth. 

Causes. — The common cause of simple stomatitis in infants is the same 
as that of most cases of gastro-intestinal inflammation at that age. This is 
the use of indigestible and therefore irritating food, uncleanliness, personal 
and domiciliary ; in fine, all those agencies which impair the general health 
and enfeeble the digestive organs. Therefore, stomatitis, like entero-colitis, 
is more common in the city than in the country, and among the city poor 
than those in the better walks of life. Infants deprived of the mother's 
milk and given a diet which, with all care of preparation, is a poor substi- 
tute for the natural aliment, are very liable to this disease. Beaumont ascer- 
tained from his experiments on St. Martin that irritative changes produced in 
the stomach by indigestible substances were soon followed by similar changes 

739 



740 STOMATITIS, 

in the buccal mucous membrane. Since in young infants any kind of arti- 
ficial food is less digestible than breast-milk, it is evident why those who are 
prematurely weaned or are carelessly fed are so liable to stomatitis. This 
inflammation is also sometimes due to irritating substances taken into the 
mouth, as drinks habitually too hot or too cold. ■ Stomatitis is also present 
in measles and scarlet fever. It then corresponds with the cutaneous erup- 
tion, and disappears when that subsides. 

Another cause is dentition. The gum over the advancing tooth first 
becomes inflamed, and, other causes perhaps conspiring, the inflammation 
extends over more or less of the buccal surface. When due to dentition the 
stomatitis is more frequently partial than when it arises from a constitutional 
cause. Mercury, in whatever form introduced into the system, excreted 
from the salivary glands and flowing over the buccal surface, is an occasional 
though, now-a-days, rare cause. 

Symptoms ; Appearances. — Stomatitis, like other mucous inflammations, 
is characterized by increased redness and more or less thickening of the 
inflamed buccal membrane, by rapid proliferation and exfoliation of epi- 
thelial cells, and by an increased functional activity of the muciparous fol- 
licles. The heat of the mouth is sometimes augmented in an appreciable 
degree. The gums in severe cases are swollen and spongy, and bleed readily 
if rubbed or pressed. The tongue is usually covered with a light fur, and 
the salivary secretion is frequently augmented to such an extent as to dribble 
from the corners of the mouth. Often there is little suffering, but in other 
instances the patients are fretful, experience pain from the contact of solid 
food, and, if nursing, may even wean themselves from dread of pressure of 
the nipple. 

Simple stomatitis is not difiicult of detection, provided that attention be 
directed to the mouth. Inspection informs us of its presence and extent. 
A favorable termination may be confidently predicted, unless there be a state 
of marked cachexia or a grave coexisting disease. If circumstances are 
unfavorable, simple stomatitis may terminate in a more severe form, as the 
ulcerous or diphtheritic. 

Treatment. — The physician should endeavor to ascertain the cause, and, 
if possible, should remove it by appropriate medicinal and hygienic measures. 
Sometimes no special treatment is required, as in measles or scarlet fever. 
When the primary affection terminates the stomatitis disappears of itself. 
If dentition be the cause and there be much fever and fretfulness, it has 
been the common practice to scarify the gums, but this operation is not often 
advisable. A few doses of bromide of potassium relieve the fretfulness, and 
mucilaginous and mild astringent lotions suffice for the catarrh. Borax is a 
good local remedy used either with honey or with glycerin and water — one 
part of borax to three of honey, or a drachm of borax to an ounce of water 
and two drachms of glycerin. A weak solution of alum is also a useful topical 
remedy. With either of these agents in a favorable condition of system, and 
without any serious coexisting disease, the stomatitis is relieved. 

Ulcerous Stomatitis. 

In ulcerous stomatitis the anatomical characters are those of severe simple 
stomatitis, with the additional element which gives it the name by which it is 
designated. 

The inflammation usually begins upon the gums and extends along the 
buccal surface. Little white points soon appear upon the under surface of 
the mucous membrane, producing slight prominence of it. These points, 
which are inflammatory exudations, mainly fibrinous, gradually enlarge. 



ULCEROUS STOMATITIS. 741 

Some unite and give rise to large irregular ulcerations ; others remain isolated, 
producing ulcers which are smaller and of more regular shape. There is, 
indeed, no uniformity as regards the size and form of the ulcers. In the 
folds of the buccal membrane they are usually elongated, while inside the 
lips or where the surface is smooth the circular or oval form predominates. 
It is a noteworthy fact that the exudation underlies the mucous membrane, 
obstructing its nutrient vessels, so that the ulcer which results causes destruc- 
tion of the mucous layer and cure is effected by cicatrization. 

Ulcerous stomatitis is usually confined to that part of the buccal surface 
which covers the gums or is in their immediate vicinity, but in some instances 
it affects nearly every part of the cavity of the mouth. 

If the disease be severe, considerable swelling occurs around the ulcers, 
but the swollen part is soft and cushiony and not very tender on pressure. 
The soft and yielding nature of the swelling serves as a means of diagnosis 
between this disease and the premonitory stage of gangrene, since in the latter 
affection the swollen part is more indurated. 

If the disease grow worse, more ulcers appear, and those already present 
grow deeper and wider and their edges more vascular. 

If, on the other hand, there be improvement, the swelling subsides, the 
ulcers become more clean, their bases approach the level of the mucous mem- 
brane, and present a granulating appearance. Finally, the mucous layer is 
reproduced. A considerable time after the ulcers are healed the new mem- 
brane which occupies their site has a redder hue than the adjacent surface. 

Causes. — Ulcerous like simple stomatitis is most frequent in the families 
of the poor. Personal uncleanliness, poor food, a residence in apartments 
dirty, humid, or in other respects insalubrious, favor its development. In 
fine, a cachectic condition, however produced, is a common predisposing 
cause. Ulcerous stomatitis frequently occurs when the system is reduced or 
enfeebled by acute diseases, as after the essential fevers and thoracic and 
intestinal inflammations. In protracted entero-colitis of infants it is some- 
times severe and obstinate, and a case in which this complication arises 
usually ends unfavorably. The abuse of mercury is an occasional cause of 
this form of stomatitis, as well as of simple catarrh. Jaccoud states that 
Bergeron established the fact that ulcerous stomatitis is propagated among 
soldiers by contagion, and he adds '• it is very probable that it is the same in 
infants." 

Symptoms. — The symptoms in ulcerous stomatitis are more severe than 
in the simple form. There are more pain, more salivation, and more fretful- 
ness. The ulcerated surface is sometimes very tender, so that there is but 
little sleep. Drinks, unless bland and lukewarm, are painful, and if the ulcers 
be on the lips or the front of the mouth the infant nurses less eagerly than 
usual, and even with reluctance, sometimes weaning itself. Occasionally 
the submaxillary glands are tumefied, hard, and tender. The breath has an 
offensive odor. In mild cases, in which the stomatitis is of limited extent, 
this odor may scarcely be noticed, but in severe cases it is almost like that 
exhaled from putrid substances. The fever is in most instances slight. 

Prognosis. — A favorable prognosis may be given unless the patient be in 
a decidedly cachectic condition or there be a serious coexisting disease, under 
which circumstances the case may be protracted. If death occur it is due to 
the cachexia or to some pathological state quite distinct from the stomatitis, 
most frequently entero-colitis. Ulcerous stomatitis when the ulcers are small 
and the inflammation of limited extent is of course more easily cured than 
when it is extensive and the ulcers are large. 

This disease is very liable to return unless the general health be good. 

Treatment. — The physician should endeavor to ascertain the cause of 



742 STOMATITIS. 

the stomatitis, and so far as possible should remove the patient from its influ- 
ence. It is often necessary, in order to ensure speedy recovery, to recommend 
a change in regimen, especially as regards diet and cleanliness. If the 
patient live in damp, dark, and dirty apartments, the family should seek a 
better residence, and he should be taken daily into the open air. 

Tonic remedies are generally required. The ferruginous preparations 
may be advantageously given, or the vegetable tonics, or the two in combina- 
tion. In selecting the internal remedies we must regard the antecedent dis- 
ease, if there be any, which the buccal inflammation complicates and on 
which it depends. For that large proportion of cases in which there is 
chronic intestinal inflammation the liquor ferri nitratis, with tincture of 
Colombo, administered in simple syrup, will be found useful. For local treat- 
ment Trousseau recommends occasional applications of nitrate of silver or 
muriatic acid as a caustic, and in the intervals a wash of equal parts of borax 
and honey. 

The chloride of lime is also considerably used in Paris. It is recom- 
mended by Rilliet and Barthez. It is applied dry to the ulcerated surface 
twice daily, and in the interval the mouth is washed with simple water. This 
treatment is continued till the ulcers present a healthy appearance and begin 
to cicatrize. Then a weak solution of chloride of lime is employed, one 
grain to forty-live of the vehicle. By this treatment a cure is usually 
efi"ected. Bouchut prefers using chloride of lime with honey, one drachm to 
the ounce. 

But painful applications are not required. The remedy which is most 
employed in this country and in Great Britain is chlorate of potassium. It 
often acts like a specific for this as well as other forms of stomatitis. It 
may be given dissolved in water with sugar or with one of the syrups, to 
render it more palatable. The dose is about two or three grains every two 
hours. It should be allowed to run over the aff'ected part, as it is believed to 
have a local action. 

R. Potass, chlorat., ,^ss-j ; 

Mellis, ,^ss ; 

Aquae, |ij. 
One teaspoonful every two hours. 

Of all topical remedies in common use, chlorate of potassium is probably 
the most efficacious. Some physicians prefer the chlorate of sodium on account 
of its greater solubility. If this wash be too painful in consequence of the 
irritable state of the ulcers, it may be mixed with mucilage or be employed 
less frequently, and borax applied in the interval. 

Aphthous Stomatitis. 

Aphthous stomatitis may occur at any age, but it is most frequent in 
childhood. It is sometimes designated follicular stomatitis, but the disease 
affects the contiguous mucous surface as well as the seat of the follicles. At 
first a vascular injection is observed, and within a few hours a whitish exuda- 
tion occurs immediately under the epithelium and upon the corium in small 
round or oval isolated spots. The smallest of these patches are not larger 
than a pin's head, but most of them have a diameter of one or two lines, 
and they cause slight prominence of the surface. In two or three days the 
exudation softens, and the epithelium which covers it is thrown off", producing 
an ulcer, superficial, without induration of its edges, but sensitive to the 
touch. It heals in one or two weeks, leaving only a reddish spot or stain, 
which soon fades. Sometimes two or more aphthae unite, forming a patch 



APHTHOUS STOMATITIS. 743 

and an ulcer of correspondingly large size. The seat of aphthous stomatitis 
is usually the internal surface of the lips and cheeks, the gums, tongue, and 
occasionally the roof of the mouth. 

Causes. — Probably in most instances the exciting cause is some derange- 
ment of the digestive organs which may not be appreciable. We sometimes 
observe this form of stomatitis in cases of diarrhoea. Occasionally, especially 
in spring and autumn, two children in a family are affected at the same 
time, or two or more in a school, so that the disease presents an epidemic 
character. Children surrounded by bad hygienic conditions, as in the tene- 
ment-houses of cities, are more liable to this as well as other forms of 
stomatitis than are children who live in clean and airy localities and have 
nutritious and wholesome diet. 

Symptoms. — The constitutional symptoms in a large proportion of cases 
of aphthae are slight. In twelve children affected with this disease Billard 
found the pulse from sixty to eighty beats per minute. 

The ulcers are painful, as is indicated by the cries of the child when 
they are pressed, and its fretfulness. Solid food, and even drinks, unless 
bland and unirritating, are badly tolerated. The salivary secretion is also 
augmented. 

In those rare cases in which the ulcers become confluent or gangrenous 
the state of the patient is really serious. There is then often gastro-intestinal 
disease. The symptoms indicate prostration. The pulse is feeble, the coun- 
tenance pallid, and the body and limbs become wasted. 

Diagnosis. — This is easy. The only disease with which it is liable to be 
confounded is ulcerous stomatitis. In the ulcerous form there is antecedent 
and accompanying stomatitis affecting a considerable part, if not the entire 
buccal cavity, while in the follicular form the inflammation is ordinarily con- 
fined to the immediate vicinity of the ulcers. The character of the ulcers 
serves also as a means of distinction. In ulcerous stomatitis there is great 
variety as to size and form, while in aphthous stomatitis there is great 
uniformity in both these respects. The small circular ulcers are character- 
istic of the follicular inflammation. Before the ulcerative stage the circum- 
scribed character of the eruption serves to distinguish this form of stomatitis 
from other local diseases affecting the cavity of the mouth. 

Prognosis. — Aphthous stomatitis usually ends favorably, but if the 
ulcers became concrete or gangrenous the health is seriously affected, and a 
more cautious prognosis should be expressed. The unhealthy appearance of 
the mouth and the real danger are more often due to the depressing effect of 
some concomitant disease than to the stomatitis. 

Treatment. — In ordinary aphthous stomatitis, which is discrete and 
attended by little or no constitutional disturbance, local remedies suffice to 
cure the disease. Demulcent drinks or applications to the mouth should 
be used, as the mucilage from gum acacia, marshmallow, or flaxseed. Mild 
astringent lotions with the demulcent are also beneficial. The mel boracis is 
one of the best and most agreeable applications. It may be placed in the 
mouth with a spoon or applied with a camel's-hair pencil. If there be much 
tenderness of the ulcers, with restlessness, a small quantity of some opiate 
should be added to the lotion or it may be administered separately. 

With this simple treatment the ulcers generally soon heal and the health 
of the patient is restored. If, however, the ulcers be painful and not disposed 
to heal, or be healing tardily, they may be touched lightly with a pencil of 
nitrate of silver, or, as Barrier recommends, hydrochloric acid in honey of 
roses. This diminishes the tenderness and expedites the healing process. A 
better remedy is iodoform, two drachms to one ounce of ether, and applied to 
the ulcers by a camel's-hair pencil. 



744 GANGRENE OF THE MOUTH. 

If, as may in rare cases occur, the ulcerations be numerous and accom- 
panied by considerable fever, there may be symptoms indicative of cerebral 
congestion or even premonitory of convulsions. In such cases laxatives and 
the soothing effect of one of the bromides, and sometimes of the warm foot- 
bath, are required. 

If there be an unhealthy appearance of the ulcers, if they gradually 
enlarge or become concrete or gangrenous, indicating a cachectic state, 
tonics should be employed with nutritious and easily-digested diet, and 
antihygienic influences should so far as possible be removed. 



CHAPTER II. 

GANGKENE OF THE MOUTH. 

The diseases of the mouth which we have been considering are attended 
by little danger, but the one which we are next to consider is among the 
most fatal of early life. It is gangrene of a portion of the cheek or gums, 
or of both. It is described by writers under various names, as cancrum oris, 
noma, necrosis infantilis, aqueous cancer of infants. 

Anatomical Characters. — Gangrene of the mouth is sometimes pre- 
ceded by ulceration of the mucous membrane at the point where it is about 
to commence, but in other cases this membrane is entire. The tissues at the 
point of attack, which is most frequently the inside of the cheek, become 
inflamed, thickened, and indurated. The induration extends, and soon the 
purple hue of gangrene appears and increases. The next stage in the prog- 
ress of gangrene is sloughing of the portion the vitality of which is lost. 

The slough does not present the appearance of uniform decay. While 
the color is generally dark, there are in the mass fibres of connective tissue, 
or even blood-vessels, which remain unchanged or are but partly decomposed. 
After separation or sloughing of the part where the vitality is first lost, the 
surface of the excavation, if the disease be not checked, has a dark, jagged, 
and unhealthy appearance. Commencing with the mucous membrane and the 
tissue immediately underlying it, the disease extends on the one side toward 
the skin and on the other toward the deeper-seated structures of the jaw. 
According to Billard, the swelling which precedes and surrounds the gangrene 
is in great part oedematous. 

This disease is occasionally primary, but in a large proportion of cases it 
is secondary. Occurring secondarily, its symptoms are often masked by those 
of the antecedent and coexisting affection. Under such circumstances 
attention is sometimes first directed to the mouth by the loosening of one or 
more of the teeth or the appearance on the skin of a livid circular spot which 
indicates the approach of the disease to the cutaneous surface. The mucous 
membrane presents a dark-red appearance to the distance of a few' lines 
beyond the point of gangrene. It covers tissues which are inflamed and 
indurated and about to iDecome gangrenous. 

The tongue is usually more or less swollen, unless the disease be mild; 
an offensive odor arises from the gangrene, due to the evolution of sulphur- 
etted hydrogen and other gases. There is great difference in the extent of 
the destruction and the gravity of the disease in different cases. It may 
sometimes be arrested by proper applications and a favorable change in the 
general health of the child at an early period, when there is little loss of sub- 



AGE— SYMPTOMS. 745 

stance. In other cases it extends till it perforates the cheek or even destroys 
a considerable part of the side of the face, and, extending inward, attacks the 
periosteum of the maxillary bone, destroying the gum and teeth and denud- 
ing the alveoli. Recovery, if it take place at all under such circumstances, 
is with the loss of a portion of the bone and with deformity. 

The duct of Steno is sometimes included in the gangrenous portion, but 
it commonly resists the destructive process and remains pervious. 

Age. — The age at which gangrene of the mouth occurs is usually between 
two and six years. In 29 cases collated by Rilliet and Barthez, 21 were 
between the ages of two and six years, and the remaining 8 between six and 
twelve years. Of the cases which have fallen under my observation, most 
were between the ages of two and six years. It is seen that the period of 
greatest frequency of gangrene of the mouth is different from that in which 
the ordinary forms of stomatitis occur. 

Gangrene of the mouth may, however, occur under the age of one year. 
Billard reported 3 cases under the age of one month, but in 2 of these the 
disease does not appear to have been sufficiently marked to render it certain 
that they were genuine cases. 

Causes. — Gangrene of the mouth usually occurs in those whose systems 
are reduced or cachectic. It is therefore more frequent among the poor than 
those in comfortable circumstances — in the city than in the country. It is 
more frequently observed in asylums for children than in private practice. 
Most of the cases which I have seen have been in these institutions. If the 
constitution be good, it can only occur in those long deprived of pure air and 
wholesome nutriment or those enfeebled by disease. 

Among the diseases which have been known to terminate in or be followed 
by gangrene of the mouth are the pulmonary and intestinal inflammations, 
whooping cough, and the fevers, both eruptive and the non-eruptive. Rilliet 
and Barthez have published a table of 98 cases in which gangrene resulted 
from various diseases. In 49 of these the antecedent disease was measles, 
in 5 scarlet fever, 6 whooping cough, 9 intermittent fever, 9 typhoid fever, 
7 mercurial salivation, and 5 enteritis. It is seen that the essential fevers 
were the most frequent cause of the gangrene. Of 46 cases collected by 
MM. Bouley and Caillault the antecedent disease was measles in all but 5. 
In this city also a larger number result from measles than from any other 
disease. 

One reason why so many cases of gangrene occur as a sequel of measles 
is probably because this disease is accompanied by stomatitis. Simple or 
ulcerous stomatitis often precedes gangrene. 

Diseases sometimes terminate in gangrene of the mouth in consequence 
of injudicious treatment which has lowered the vitality of the system. Eil- 
liet and Barthez mention the case of a child four years old in whom gangrene 
commenced at the twenty-ninth day of primitive pneumonia. The child had 
been reduced by the application of twelve leeches, three scarifications, a large 
blister, and by a poor diet. 

The misuse of mercury was once a much more frequent cause of gan- 
grene than at present, at least in this country, since this agent was formerly 
much more employed than now. In fact, most of the aifections of infancy 
and childhood in which mercurials were formerly employed are now treated 
without it. 

Symptoms. — Gangrene of the mouth so often occurs in connection with 
other diseases that its symptoms are in a large proportion of cases blended 
with those which arise from a distinct pathological state. 

There is usually prostration more and more pronounced as the gangrene 
extends. The features are ordinarily pallid, but occasionally their normal 



746 



GANGRENE OF THE MOUTH. 



color is preserved for a time ; the expression of the face is melancholy, but 
composed. Sometimes the child is fretful if disturbed ; at other times it 
will quietly consent to an examination. The suffering is not proportionate to 
the gravity of the disease. There is less pain often than in some of the forms 
of stomatitis which are unattended with danger; 

As the disease advances the body and limbs gradually waste, the eyes are 
hollow, or, if the gangrene be near the orbit, the eyelids become oedematous ; 




the lips are infiltrated ; and both the lips and nostrils are often incrusted. If 
the cheek be perforated, alimentation is rendered difiicult and the appearance 
of the child is melancholy in the extreme. 

The tongue is usually moist; it is occasionally swollen. The saliva flows 
from the mouth, either pure or mixed with offensive sanguinolent matter. 
Unless the disease be slight there is the peculiar gangrenous odor. The 
appetite is sometimes poor; at, other times it is preserved through the whole 
sickness. There is no vomiting or looseness of the bowels, unless from a 
complication. The thirst is usually great, and the pulse is accelerated and 
feeble except in mild cases. 

The skin in the commencement of gangrene is hot. When the vital force 
is much reduced, and especially as the disease approaches a fatal termination, 
the face and limbs become cold and the surface generally presents a waxen 
or ashy appearance. No derangement occurs of the respiratory system. 
Those cases which are attended by a cough or accelerated respiration are 
really cases of bronchitis or pneumonia coexisting with the gangrene. 

Diagnosis. — Gangrene of the mouth is easily diagnosticated. In those 
cases in which ulceration precedes the gangrene it may be mistaken in its first 
stage for that form of ulcerous stomatitis in which the ulcers assume an 
unhealthy appearance. The following are the distinguishing features of the 
two affections : Around the ulcer where gangrene is about to commence the 
tissues are greatly thickened and indurated or oedematous, while ulcerous 



PROGNOSIS. 747 

stomatitis begins with a sabmucous deposit of fibrin, and is attended by little 
thickening of th6 surrounding parts and little or no induration or oedema. In 
ulcerous stomatitis the skin over the seat of the disease presents its normal 
appearance, whereas in gangrene it presents a distended and shining appear- 
ance. The destructive process in ulcerous stomatitis is also more limited 
than in gangrene. Deep ulcerations do not occur or are rare. Ulcerous 
stomatitis is more readily healed, and it leaves no eschar, contraction, or 
deformity. 

The differential diagnosis of gangrene of the mouth from those cases of 
follicular stomatitis in which the ulcers occupying the seat of the follicles 
assume a gangrenous appearance must be made by a consideration of the same 
facts or particulars which serve to distinguish it from ulcerous stomatitis. 

Malignant pustule, of rare occurrence in the child, resembles this disease 
in some of its features. But the pustule always begins on the skin, while 
gangrene is a disease of the mucous surface primarily. In gangrene, there- 
fore, the chief destruction is of the mucous membrane and of the submucous 
tissue, while in malignant pustule the chief destruction is of the skin and the 
subcutaneous tissue. 

Prognosis. — -This depends not only on the extent of the gangrene, but 
the nature of the disease, if there be one, which gave rise to it, and the 
degree of cachexia. If it occur in connection with or as a sequel to one of 
the less debilitating diseases, and there be considerable vigor of system, it 
may often be arrested when it has destroyed only the mucous and subcuta- 
neous tissues, so that no deformity results. The friends may congratulate 
themselves if the case terminate so favorably. In the graver cases, when 
the gangrene extends until it destroys the periosteum of the maxillary bone 
on the affected side, and perhaps perforates the cheek, if the child recover it 
is with the permanent loss of teeth, tedious separation of the necrosed bone, 
and a cicatrix which may interfere with the free use of the jaw. Death is, 
however, the more common termination of severe cases. Occasionally the 
gangrene destroys the continuity of a blood-vessel, causing abundant hem- 
orrhage and accelerating the fatal result. In most cases, however, there is 
little or no hemorrhage in consequence of coagulation in the vessels. 

Another serious complication sometimes arises — to wit, gangrene of other 
parts, as of the external genital organs. The English editor of Bouchut's 
treatise on diseases of children relates the following interesting case, from 
the Transactions of the Edinburgh Medico- Chir. Society: An infant eight 
months old became affected with gangrene of the face, head, and hands. 
^' The right ear and the entire hairy scalp were of an intensely black color, 
and on both cheeks patches existed about the size of a half-crown piece. 
The right thumb and the backs of both hands were similarly affected. The 
child was noted to have been restless and feverish on May 22d, and on the 
23d a slightly darkfened ring was found to have formed round the thumb, 
about the middle of the first phalanx : in a few hours the whole thumb was 
gangrenous and the dorsum of the hand became involved. On the ear the 
gangrene commenced with the appearance of a flea-bite, and subsequently 
extended rapidly to the scalp, assuming a remarkably regular form and giv- 
ing to the child the appearance of wearing a black skull-cap. The pulse was 

observed to be very feeble Death took place in twelve hours from the 

first appearance of gangrene on the thumb, the child being sensible and con- 
tinuing to suck well up to a few minutes before death." 

Rilliet and Barthez state that pneumonitis frequently occurs in the course 
of gangrene of the mouth. Such a complication evidently diminishes mate- 
rially the chance of recovery. 

Whether the result be favorable or unfavorable, it is evident from the 



748 GANGRENE OF THE MOUTH. 

nature of the disease that the duration is very different in different cases. 
The physician's attendance may be required for a week or two or for several 
weeks. 

Treatment. — As gangrene of the mouth is eminently a disease of debil- 
ity, all antihygienic influences should be removed and the most nourishing 
diet, together with tonics, be recommended. The ferruginous preparations or 
the bitter vegetables are required. 

x\s soon as the physician is called he should endeavor to arrest the gan- 
grene, accelerate detachment of the slough, and produce a healthy and gran- 
ulating state of the surrounding tissues. This is best effected by applying a 
highly stimulating or even escharotic agent to the inflamed surface under- 
neath and around the gangrene. For this purpose a great variety of sub- 
stances have been used by different physicians, such as acetic, sulphuric, 
nitric, and hydrochloric acids, nitrate of silver, the acid nitrate of mercury, 
chloride of antimony, carbolic acid, and even the actual cautery. 

M. Taupin recommends, after removing a considerable part of the gan- 
grenous substances with scissors or some instrument, the application of strong 
muriatic acid, and, when the slough is detached, of dry chloride of lime. 

Rilliet and Barthez advise the use twice daily of muriatic acid or the 
acid nitrate of mercury, applied by a brush upon and around the slough, 
followed immediately by the application of dry chloride of lime, when the 
mouth is to be thoroughly washed with water from a syringe. They direct 
in the interval frequent ablution with water. After the slough has separated, 
the escharotic is to be discontinued and the chloride of lime used alone. If 
gangrene extend to the skin, a crucial incision is to be made and the eschar- 
otic applied, after which powdered cinchona is introduced and retained by a 
plaster. This treatment is to be continued till the gangrene is arrested and 
the decayed portion removed. Barrier, Valleix, and most French writers 
recommend essentially the same treatment — namely, the application of undi- 
luted escharotic agents. 

A safer, less painful, and in many cases successful treatment is that 
employed by many British and American physicians — to wit, the use of 
escharotic agents diluted, or, if applied in their full strength, such as are 
least active and penetrating. Some employ from the first topical treatment 
which is astringent and stimulating rather than escharotic, and they report 
satisfactory results. 

Dr. Gerhard believes " the best local applications are the nitrate of silver, 
if the slough be small in extent; if much larger, the best' escharotic is the 
muriated tincture of iron, applied in the undiluted state. After the prog- 
ress of the disease is arrested the ulcer will improve rapidly under an astrin- 
gent stimulant, such as the tincture of myrrh or the aromatic wine of the 
French Pharmacopoeia." 

The local treatment recommended by Evanson and Maunsell differs from 
that advised by any of the writers from whom I have quoted. A knowledge 
of this treatment, from which I have myself seen good results, will be best 
imparted by quoting from these authors:^ " The lotion which we have found 
by far the most successful is a solution of sulphate of copper as employed 
by Coates in the Children's Asylum. His formula is as follows: 

R. Cupri sulph., ,^ij ; 

Pulv. cinchonfe, .|ss; 

Aquae, ^iv. Misce. 

" This is to be applied twice a day very carefully to the full extent of the 
ulcerations and excoriations. The addition of the cinchona is only useful by 
^ Biseaf^es of Children, 2d Amer. ed., p. 188. 



TREATMENT. 749 

retaining the sulphate of copper longer in contact with the edges of the gums. 
A solution of the sulphate of zinc, ^j to an ounce of water, by itself or com- 
bined with tincture of myrrh. Dr. Coates found to be also useful in some 
cases." 

A moment's reflection will show us that the above treatment is preferable, 
provided that it is equally effectual in arresting the gangrene, to the treat- 
ment by the strong acids which are in common use, and the efficiency of 
which cannot be questioned. 

The purpose in applying the acid is to establish a healthier state of the 
tissues. It cauterizes and destroys whatever soft tissue it comes in contact 
with ; besides, it produces a strong corrosive action on the teeth and bone. 
Therefore in gangrene affecting the jaw there is great danger that it will 
destroy the periosteum, and consequently increase the necrosis. 

Dr. West,^ who advocates the use of the acid, says : " In one of the cases 
that I saw recover the arrest of the disease appeared to be entirely owing to 
this agent, though the alveolar processes of the left side of the lower jaw, 
from the first molar tooth backward, died and exfoliated, apparently from 
having been destroyed by the acid." No such result follows the use of the 
solution of sulphate of copper. 

In one of these severe cases in which the disease resulted from scarlet 
fever, and in which there was so much debility that an unfavorable prog- 
nosis was made, I succeeded in arresting the disease by the use of Dr. 
Coates's prescription. The child recovered with the loss of two teeth and 
the corresponding portion of the maxillary bone. From the good effects 
which I have observed from iodoform as an application for gangrenous vul- 
vitis following measles it has occurred to me that it may also be useful in 
gangrene of the mouth. 

If, after employing the milder treatment i'or two or three days, the gan- 
grene continue to spread, the strong muriatic acid should be cautiously 
applied by a camel's-hair pencil or small swab in such a way that it comes in 
contact only with the diseased surface. Its use should be immediately fol- 
lowed by an alkaline wash, as a solution of sodium bicarbonate. 

In 1881 an epidemic of measles occurred in the New York Foundling 
Asylum during the attendance of Drs. O'Dwyer and Lee. The number of 
children affected with it was 165, and, since many of them were cachectic, 
we were not surprised that gangrene appeared as a complication or sequel in 
7 cases. In a girl of three and a half years it appeared upon the upper 
jaw at the base of the teeth ; in two girls of four years it appeared upon 
the inside of the cheek and upon the vulva, and not upon the gums ; in a 
boy of three years it attacked the lower jaw, destroying four teeth with 
their sockets, and the upper jaw, destroying five teeth, with the correspond- 
ing portion of the maxillary bone, so that all the incisors and one canine 
were lost, as well as the cartilaginous portion of the nasal septum. Gan- 
grene also occurred in the groin in this case. Another boy of three and a 
half years lost two incisors from gangrene of the jaw. The treatment by 
muriatic acid was employed, and, according to the house physician. Dr. Kort- 
right, there was no further extension of the gangrene after the first applica- 
tion in any of the cases. All lived except the first, who had broncho-pneu- 
monia. The remaining two patients, aged respectively four years, died of 
diphtheria and pneumonia before treatment could be tested. One of them 
had commencing gangrene of the lower jaw, the other of the soft palate. 
Recently, in the Foundling Asylum carbolic acid has been used as an eschar- 
otic in one or two cases, instead of the strong acid, and with such a result 
as to encourage its further use. 

' Diseases of Children, 4th Anier. ed. 



750 DENTITION. 

The gases arising from the gangrenous mass are not only highly offensive 
to others, but they are doubtless injurious to the patient, who is constantly 
inhaling them. To remove the fetor, chlorine or carbolic acid, properly dilu- 
ted, should be occasionally used between the applications of the sulphate of 
copper. Labarraque's solution, one part to eight or ten parts of water, is an 
eligible form for its use. When the gangrene is removed and the granula- 
tions present a healthy appearance, all danger is usually past and convales- 
cence is fully established. Then no energetic topical treatment is required. 
A mild stimulating lotion, like the tincture of myrrh, as recommended by 
Dr. Gerhard, suffices, with the aid of tonics and nutritious diet. 



CHAPTER III. 

DENTITION. 

The opinion formerly entertained in the profession, and now prevalent in 
the community, that many infantile maladies arise directly or indirectly from 
dentition is erroneous. Still, there are physicians of experience who believe 
that teething is a common cause of certain maladies, especially of functional 
derangements, even of organs remote from the mouth. On the other hand, 
equally good observers — and the number is increasing — almost wholly ignore 
the pathological results of dentition. They say that as it is strictly a phys- 
iological process it should, like other such processes, be excluded from the 
domain of pathology. 

A moment's reflection will show how important it is to understand the 
exact relation of dentition to infantile diseases. Every physician is called now 
and then to cases of serious disease, inflammatory and non-inflammatory, which 
have been allowed to run on without treatment, in the belief that the symp- 
toms were the result of dentition. I have known acute meningitis, pneumo- 
nia, and entero-colitis, even with medical attendance, to be overlooked, and 
the symptoms attributed to teething during the very time when appropriate 
treatment was most urgently demanded. Many lives are lost from neglected 
entero-colitis, the friends believing the diarrhoea to be symptomatic of denti- 
tion, a relief to it, and therefore not to be treated. Such mistakes are trace- 
able to the erroneous doctrine, once inculcated in the schools, and still held 
by many of the laity, that dentition is directly or indirectly a common cause 
of infantile diseases and derangements. 

I shall endeavor to point out what is really ascertained in regard to the 
pathological relations of dentition. 

The first dentition commences at the age of about six months and termi- 
nates at the age of two and a half years. The corresponding teeth of the 
two sides pierce the gum at about the same time. The two inferior central 
incisors first appear at about the age of six or seven months, followed, in the 
order in which they are mentioned, by the upper central incisors, upper lat- 
eral incisors, lower lateral incisors, the four anterior molars, the four canines, 
and, lastly, the four posterior molars. 

The incisors usually appear in rapid succession, so that all are in sight by 
the age of one year. From the age of one year to eighteen months the 
anterior molars appear, and from the age of sixteen to twenty-four months 
the canines, and from twenty-four to thirty months the posterior molars. 
This order is not always preserved. Sometimes the upper central incisors 



PATHOLOGICAL RESULTS OF DENTITION. 751 

appear before the lower, and sometimes the lower lateral before the upper 
lateral. In rare cases there have been teeth at birth. I have seen but one 
or two infants with such premature dentition. Retarded dentition is much 
more common. Those who have rickets or are feeble either constitutionally 
or by disease often have no teeth till considerably after the usual period. 
In such the first incisors may not appear till the age of twelve months, or 
even later. 

Pathological Results of Dentition. — The evolution of the teeth is 
commonly attended by more or less turgescence around the dental bulbs. 
This is greater with some of the teeth than with others. Thus the superior 
incisoTs cause more swelling than do their congeners of the inferior jaw. The 
turgescence, although attended by more or less congestion, is physiological 
within certain limits, and not a disease. 

But sometimes there is an unusual amount of swelling around the dental 
follicles ; the afflux of blood to them is greatly augmented ; they are the 
seat of such a degree of tenderness and pain that the infant is fretful. It 
carries the finger often to the mouth, indicating the seat of its suffering. The 
surface over the follicles presents greater redness than in ordinary dentition, 
and the salivary secretion is considerably increased. There is now actual 
gingivitis. 

Occasionally the inflammation affects a greater extent of the buccal sur- 
face than that lying directly over the follicles, so that most writers speak of 
stomatitis as one of the results of dentition. In a few cases I have known 
such a degree of inflammation over the advancing tooth that a small abscess 
formed, producing much pain and restlessness till it was opened by the 
lancet. 

The pathological results of dentition which I have mentioned, though they 
may interfere more or less with nursing or feeding, are not dangerous. They 
are easily detected. They result directly from the rapid growth and aug- 
mented sensitiveness of the dental follicles. 

There are other supposed accidents of dentition occurring in distant parts 
of the system in consequence of the relation and interdependence of organs 
which exist through the system of nerves. 

Some children previously to the eruption of the teeth are affected with 
diarrhoea, occasionally accompanied by irritability of stomach. Certain writers 
have supposed that gastro-intestinal catarrh is present in these cases ; others 
that there is simply a hypersecretion, an increased activity of the intestinal 
follicular apparatus — that it is, in other words, one of the forms of non- 
inflammatory diarrhoea. Barrier believes that the diarrhoea of dentition 
depends usually on what he calls a " subinflammatory turgescence limited to 
the gastro-intestinal follicular apparatus." He believes that in occasional cases 
it is due to defective or altered innervation. It would then be analogous or 
similar to that form of diarrhoea w'hich occurs in the adult from the emotions. 
Bouchut calls the diarrhoea of dentition nervous diarrhoea. It is certain^ 
however, that in most cases of diarrhoea which are attributable to dentition 
there are other causes, such as unsuitable food or residence in an insalubrious 
locality. It is certain, as regards city infants, that the chief causes of diar- 
rhoea during the period of dentition are strictly antihygienic, dentition being 
quite subordinate as a cause, and probably ordinarily not operating at all as 
such. But when, as sometimes happens, at each period of dental evolution 
the infant is affected with diarrhoea, the influence of teething is apparent. 
Such cases enable us to see that teething may really sustain a causal relation 
to certain diseases not located in the buccal cavit}^ 

Among the more common pathological results of difficult dentition are 
certain affections referable to the cerebro-spinal system. Eclampsia is one 



752 DENTITION. 

of the admitted results. Barrier attributes convulsions in the teething infant 
to excitement of the nervous system arising from the pain which is felt in 
the gums, and to a determination of blood to the dental apparatus, in which' 
afflux the whole vascular system of the head participates. 

In most cases of convulsions occurring during the period of dental evolu- 
tion a careful examination discloses other causes in addition to the state of the 
gums. Difficult dentition must then be considered not so frequently a direct 
as a co-operating or predisposing cause, producing a sensitive state of the 
nervous system, or possibly an afflux of blood to the head, of which Barrier 
speaks, and which by an additional stimulus, perhaps trivial in itself, ends in 
convulsions. In exceptional instances eclampsia occurs mainly from denti- 
tion, or if there are other causes they are quite subordinate. This may hap- 
pen when several teeth penetrate the gum at or about the same time. Infants 
who are burned or scalded are very liable to clonic convulsions. This is. in 
fact, the chief danger as regards life from such accidents. So the swollen 
and tender gum, if several teeth are about emerging, may affect the cerebro- 
spinal system like the burn or scald and produce the same nervous phenomena. 
Thus in a case already alluded to in the chapter on Convulsions, five incisors 
pierced the gum within about two weeks, and in this period there were two 
attacks of eclampsia with an interval of a few days. The attacks were not 
severe, and the most careful examination could discover no other cause than 
the simultaneous development of so many dental follicles. Previously and 
since the infant has been well. 

Dentition sometimes, though rarely, occasions also tonic contraction of 
certain muscles. The following case occurred in the practice of the late Dr. 
A. S. Church of this city, the history of which he communicated, as follows : 

Case. — "H , seven months old, was first visited April 3, 1863. The 

patient had been fretful for several days, but about daylight on the morning of 
my first visit it commenced crying, and had not ceased for a moment at the time 
of my visit, 9 A. M. The bowels w^ere somewhat constipated and tympanitic ; 
abdominal muscles very tense. The pain w^as supposed to be in the abdomen, 
and a brisk cathartic, to be followed by an anodyne, was ordered. Some relief 
followed, but on the ensuing and for several consecutive mornings the pain 
returned, each day lasting longer, until the child only ceased crying while under 
the influence of a full anodyne. The gum over the upper incisors w^as consid- 
erably swollen, hot, and dry, but the parents w^ould not consent to have it scarified. 
For the first week there was no fever, no vomiting, and not the least indication 
that the nervous system was suffering. About the 10th the thumbs were noticed 
to be flexed during the attack of pain, and about the 15th the flexors of the toes 
were contracted and the hands were turned backward and outward, but only while 
the child w^as awake. About the 20th there was constant contraction of the 
flexors of both extremities, with opisthotonos, and constant rolling of the head, 
loss of appetite, progressive emaciation, coated tongue, and highly-inflamed gums. 
Consent was finally obtained to relieve the inflamed gum, and free incisions were 
made, and the following night the child slept comfortably for three hours with- 
out opiates. In three days the gums were freely cut again, and the teeth soon 
made their appearance. All symptoms of disease had now ceased, the child 
became playful, and on the 30th the patient was discharged." 

More recently a child of about eighteen months, seen by me in consulta- 
tion, had tonic contraction of the flexors of the left thigh and leg, continuing 
nearly a month, so that the thigh was flexed on the body and the leg on the 
thigh. The infant was cutting five teeth at the time, and the gums were 
considerably swollen over them. The normal state of the aff'ected limb 
was not restored until these teeth had penetrated the gum. 

The opinion has been prevalent in the profession that painful and difficult 
dentition is one of the chief causes of infantile paralysis, but it is now com- 



DIA GNOSIS— TREA TMENT. 753 

monly admitted that it is only a subordinate or remote cause, if indeed it is 
proper to consider it as a cause at all. (See art. Paralysis.) 

Some writers express the opinion that acute meningitis occasionally results 
from teething. The facts, however, that are relied upon to prove this are 
uncertain. The occurrence of meningitis during dentition is probably in most 
instances a coincidence. 

Teething less frequently disturbs the respiratory system than either the 
digestive or cerebro-spinal. A cough occurs in some infants at each period 
of dental evolution. It is attended by little expectoration, but appears to be 
associated with, in at least certain cases, an inflammatory turgescence of the 
bronchial mucous membrane. 

Acceleration of pulse is often observed at the time of greatest swelling 
and tenderness of the gum. It subsides with the protrusion of the tooth. 
The fever of dentition is irregular, sometimes presenting a remittent form, like 
remittent fever or the fever premonitory of meningitis. Eczema and certain 
other cutaneous diseases are common during dentition, but their dependence 
on it as a cause has not been demonstrated. 

Diagnosis. — The accidents of dentition which are located in the mouth 
are easily diagnosticated, except the odontalgia which writers describe, and 
which is not necessarily attended by any perceptible anatomical alteration of 
the gums. Those accidents which pertain to remote and concealed organs 
are usually detected with ease, though it is often difficult to determine with- 
certainty their relation to dentition. 

When similar symptoms arise at each epoch of teething and subside with 
the subsidence of the gingival turgescence, teething must be regarded as the 
cause. Or, if the disease be such as is known to be produced occasionally 
by difficult teething, and if, after a careful examination, we can discover no 
other cause, while the gums are swollen, especially over two or more advan- 
cing teeth, it is proper to refer the malady to dentition. 

It is evident that we must often be in doubt whether the disease we are 
treating be due at all to the state of the gums, or, if so, whether directly or 
indirectly or to what extent ; but as a rule if any other cause be apparent we 
may properly regard the influence of dentition as quite subordinate. 

Treatment. — It is obvious that remedial measures in cases of difficult 
dentition must be twofold — namely, those directed to the state of the gums, 
and those designed to relieve the derangements or diseases to which denti- 
tion has given rise. If there be diarrhoea, this should be controlled by 
proper remedies, so as to reduce the number of evacuations to two or three 
daily. It is well to state to the friends of the child who believe that 
diarrhoea is salutary during the period of teething that this number is 
quite sufficient, and that more frequent evacuations endanger the safety of 
the child. 

The nervous affections, as convulsions, require such soothing and deriva- 
tive measures as are recommended in our remarks on Diseases of the Nervous 
System. The bromide of potassium I have found especially useful and safe 
in cases of fretfulness and nervous excitement due to dentition. Demulcent 
and soothing lotions are sometimes useful in cases of painful dentition, and 
the infant may be allowed to hold in its mouth an India-rubber or ivory 
ring, which seems to give considerable relief. 

Mothers often attempt to " rub through a tooth," as they term it, by 
means of a ring or thimble. This should be discouraged. So great friction 
cannot fail to have an injurious effect by increasing the swelling and inflam- 
mation, unless the tooth have already reached the mucous membrane. 

We come now to a subject which has engaged the attention of many 
physicians of ample experience, and in reference to which there is still a dif- 
48 



754 DENTITION. 

ference of opinion among the highest authorities in medicine. I refer to 
scarification of the gums. 

The gum-lancet is much less frequently employed than formerly. It is 
used n)ore by the ignorant practitioner, who is de^cient in the ability to 
diagnosticate obscure diseases, than by one of intelligence, who can discern 
more clearly the true pathological state. Its use is more frequent in some 
countries, as England, under the teaching of great names, than in others, 
as France, where the highest authorities, as Rilliet and Barthez, dis- 
countenance it. 

It is well to bear in mind, as aiding in the elucidation of this subject, the 
remark made by Trousseau, that the tooth is not released by lancing the gum 
over the advancing crown. The gum is not rendered tense by pressure of 
the tooth, as many seem to think, for if so the incision would not remain 
linear, and the edges of the wound would not unite, as they ordinarily do 
by first intention within a day or two. This speedy healing of the incision 
unless the tooth be on the point of protruding is an important fact, for it 
shows that the effect of the scarification can last only one or two days. The 
early repair of the dental follicle is probably conservative, so far as the 
development of the tooth is concerned. It may help us to understand how 
active, how powerful, the process of absorption is, if we reflect that the roots 
of the deciduous teeth are more or less absorbed by the advancing second 
set, without much pain or suffering from the pressure. If the calcareous 
particles of the teeth are so readily absorbed, what is the foundation for the 
belief that the fleshy substance of the gum is absorbed with such difficulty ? 
Too much importance has evidently been attached to the supposed tension 
and resistance of the gum in the process of dentition. 

Follicles in the period of development are especially liable to inflamma- 
tion. We see this in the follicular stomatitis and enteritis so common when 
the buccal and intestinal follicles are in a state of most rapid growth. Does 
not this law in reference to the follicles hold true of those by which the teeth 
are formed, so that the period of their enlargement and greatest activity, 
which corresponds with the growth and protrusion of the teeth, is also the 
period when they are most liable to congestion and inflammation ? It seems 
probable that the dental follicles are most liable to become inflamed, and 
therefore tender, from various causes apart from dentition at the time of their 
greatest functional activity. 

If there be no symptoms except such as occur directly from the swelling 
and congestion of the gum, the lancet should seldom be used. The patho- 
logical state of the gum which would, without doubt, require its use is an 
abscess over the tooth. As to the symptoms which are general or referable 
to other organs, as fever and diarrhoea, the lancet should not be used if the 
symptoms can be controlled by other safe measures. All co-operating causes 
should first be removed, when in a large proportion of cases the patient will 
experience such relief that scarification can be deferred. 

If the state of the infant be one of immediate danger, as in eclampsia, 
and it be not quickly relieved by the ordinary remedies, scarification may 
not only be proper, but required to ensure safety. For in such cases all 
measures, provided that they are safe and simple, which can possibly give 
relief, should be employed without delay. But I can recall to mind only three 
accidents of dentition which would be likely to be benefited by scarification — 
namely, suppurative inflammation in the dental follicle, extreme fretfulness 
continuing day after day, and convulsions. But since the bromide of potas- 
sium and hydrate of chloral have come into use as nervous sedatives and as 
efficient remedies for clonic convulsions, scarification of the gums is much less 
frequently required, for even severe eclampsia commonly yields to these medi- 



TREATMENT. 755 

cines if the condition of the bowels be attended to. In some instances I have 
found that the elixir anisi (aniseed cordial) of the National Formulary, con- 
taining as it does anethol and the oils of fennel and bitter almonds, admin- 
istered in doses of ten drops to an infant of one year, is apparently more 
quieting in cases of restlessness than the bromide. It may be given with 
the bromide. 

Second Dentition. 

The fact is well established, though often overlooked in practice, that 
second dentition occasionally deranges the functions of organs and gives rise 
to pathological symptoms. Rilliet and Barthez mention particularly neuralgic 
pains, rebellious cough, and diarrhoea as effects which they have observed. 
Rilliet relates the case of a girl eleven years old who had a very obstinate 
and protracted cough, the paroxysms lasting often half an hour to one hour. 
This cough immediately and permanently disappeared when the molars pierced 
the gums. 

JDr. James Jackson ^ says : " I have seen persons between twenty and 
thirty years of age much aff'ected by a icis'hm tooth not yet protruded, and 
distinctly relieved by cutting the gum. But I think the most common period 
of suff'ering from the second dentition is from the tenth to the thirteenth 
year. The most characteristic aff'ections are wasting of flesh and nervous 
diseases. The boy loses his comeliness and his complexion is less clear, while 
emaciation takes place in every part, though mostly perhaps in the face. 
The nervous symptoms are various, but the most common are a change in 
the temper and a loss of spirits. With these there is some loss of strength. 
The patient is unwilling to engage in play, and soon becomes tired when he 
does do it. Among the distinct symptoms which are not uncommon I may 
mention pain in the head and in the eyes. The headache is not commonly 
severe, but it is such as inclines the patient to keep still. The eyes are not 
only painful, but are often aff'ected with the morbid sensibility to which these 
organs are subject. I have known boys truly anxious to pursue their studies 
obliged to give them up on this account ; and these, not having the disposi- 
tion to play, will of choice pass the day with their mothers and increase their 
troubles for the want of air and exercise. Nervous aff'ections of a more severe 
character are sometimes manifested." 

Whether the symptoms which have been attributed to second dentition 
have alwaj's been due to this cause is questionable. Practically, however, it 
matters little whether we recognize dentition as the cause or assign some- 
thing else. Hygienic and medicinal measures to improve the general health 
will usually suffice to relieve the patient. Elsewhere I have related the case 
of a boy of nervous temperament, about seven years old, who recovered 
immediately from a cough which had lasted for several weeks by taking a 
mixture of iron and nitric acid. Many do well without medicine, simply by 
hygienic measures. Dr. Jackson says : " The remedies which I have found 
most useful are as follows : First, a relief from study or from regular tasks, 
yet using books so far as they aff'ord agreeable occupation or amusement. 
Second, exercise in the open air, preferring the mode most agreeable to the 
patient, and in more grave cases the removal from town to country." 

^ Letters to a Young Physician. 



756 CATARRHAL PHARYNGITIS. 



CHAPTEE IT. 

CATARRHAL PHARYNGITIS, PERIPHARYNGEAL ABSCESS, 
(ESOPHAGITIS. 

Catarrhal Pharyngitis. 

Children of all ages are liable to inflammation of the pharynx. In its 
mildest form it often, doubtless, escapes detection in the young infant. In 
older patients it is revealed by pain in swallowing solid food and more or less 
tumefaction below the ears, apparent to the sight. It is said to be less fre- 
quent in infancy than in childhood. In the adult and in children over the 
age of four or five years inflammation of the pharyngeal surface is often con- 
fined to the portion of membrane which covers or immediately surrounds the 
tonsils. It occurs in connection with inflammation of these glands. But in 
infancy and early childhood this limitation is comparativelj^ rare. Catarrhal 
inflammation of the fauces at this age is ordinarily general, the tonsils par- 
ticipating in the morbid state. 

Pharyngitis is primary or secondary. The secondary form occurs in mea- 
sles, scarlet fever, bronchitis, croup, pneumonia, and occasionally in other 
afl'ections. As these diseases are common, physicians are oftener called to treat 
patients who have the secondary form than the primary. Rilliet and Barthez 
met 83 secondary to 16 primary cases. 

ANATOiMiCAL CHARACTERS. — The pathological anatomy of pharyngitis is 
ascertained by depressing the tongue and inspecting the fauces. The faucial 
surface is seen to be redder than in health, with more or less swelling accord- 
ing to the intensity of the inflammation. In the primary inflammation the 
color is commonly bright red, almost like that of arterial blood. If, on the 
other hand, the inflammation occur in connection with a constitutional malady, 
the hue is often darker. In grave cases of scarlet fever or measles it is some- 
times even livid, indicating a vitiated state of the blood — a condition of real 
danger. The tonsils are tumefied so as to project, though not to the extent 
which we observe in the adult. They are less firm than in the normal 
state. The follicles of the throat are enlarged and active, pouring out a 
muco-purulent secretion. This is sometimes seen in a layer over the tonsil 
or the posterior portion of the fauces. In a case of primary pharyngitis 
examined after death by Rilliet and Barthez the tonsils were softened, infil- 
trated with pus, and slightly enlarged. A layer of bloody mucus lay on the 
pharyngeal surface, which was dark red and thickened. The submaxillary 
glands were also swollen and somewhat softened. 

If the inflammation be intense the deep-seated portions of the tonsils 
become involved, and even sometimes the adjacent connective tissue. In such 
cases by applying the fingers in the hollows below the ears the tonsils "can be 
felt. 

Causes. — The usual cause of primary pharyngitis is exposure to cold. 
It also occasionally occurs from the use of drinks too hot or containing some 
irritating substance. I have met it in the most intense form caused by swal- 
lowing boiling water, and in one case from acetic acid taken through mis- 
take. When it occurs in the eruptive fevers it is usually part of a more 
extensive phlegmasia in which the buccal and perhaps laryngeal and nasal 
surfaces participate. 



SYMPTOMS— DIAGNOSIS. 757 

Symptoms. — Fever, with thirst and loss of appetite, is common, and is 
usually proportionate in intensity to the extent and severity of the inflamma- 
tion. At first there is dryness of the faucial surface, and this is succeeded 
by a more or less abundant viscid secretion. Swallowing is painful, except 
in mild cases. The muscles of the anterior half arches, which by their con- 
traction close the opening from the pharyngeal to the buccal cavity, and those 
of the posterior arches, which close the opening to the nasal cavity, both 
which sets lie a little under the mucous membrane, are often so infiltrated 
with serum that their contractile power is diminished, and if the same happen 
with the constrictor muscles, which carry downward the food, swallowing 
becomes difiicult, and in the attempt more or less of the ingesta is liable to 
return into the mouth or enter the nostril. During health the air passes 
through the nostrils in the pronunciation of two letters only — namely, n and 
7n — but in severe pharyngitis, in consequence of the swelling and the impair- 
ment of the action of the muscles concerned in speech, the air passes through 
the nostrils with the utterance of many words, producing the nasal tone of 
voice. Sometimes the inflammation traverses the Eustachian tube to the 
middle ear, causing earache, which may be relieved by the escape of pus down 
the tube or by perforation of the drum into the external ear. 

The breath is foul, but not fetid ; the respiration normal or but slightly 
accelerated ; there is commonly no cough, but it is sometimes present, due to 
the extension of the inflammation to the upper part of the larynx or to the 
collection of mucus around the aperture of the glottis. In most cases of 
pharyngitis a light fur covers the tongue, and stomatitis of a mild grade 
is present, as shown by redness of the buccal surface and increased mucous 
secretion. 

Chronic pharyngitis, which is so common jn adults, and which is produced 
in some by gastric derangements, and in others by excessive smoking or the 
prolonged use of intoxicating drinks, and in others still by the syphilitic or 
mercurial cachexia, is comparatively rare in children. 

Prognosis. — In mild cases of pharyngitis convalescence commences 
within a week. If the inflammation be dependent on a constitutional malady, 
it may continue considerably longer, especially if the glands of the neck and 
the connective tissue be much involved. The prognosis in secondary pharyn- 
gitis is less favorable than in that of the primary form. In fatal cases there 
is usually a vitiated state of the blood, either from the coexisting constitu- 
tional disease or from previous cachexia. 

Pharyngitis may, however, become dangerous from complications to which 
it gives rise. The proximity of the inflammation to the brain or its eff"ect 
upon the cerebro-spinal axis through the medium of the nerves sometimes 
gives rise to clonic convulsions. In a recent case of primary pharyngitis in 
my practice repeated and violent convulsions occured in an infant about one 
year old from this cause. They commenced at the inception of the inflamma- 
tion, and constituted the only real danger. Pharyngitis may interfere mate- 
rially with nutrition in consequence of the dysphagia, but in most cases of 
primary pharyngitis this symptom does not continue sufficiently long to 
endanger the life of the patient. In grave constitutional aff"ections, as scarlet 
fever, the difficulty of swallowing and the consequent innutrition augment 
the danger. As regards, therefore, the prognosis in catarrhal pharyngitis, 
whether primary or secondary, it may be stated as a rule that it is not, per se, 
a. fatal disease, but is only so from complications or from aggravating the pri- 
mary malady with which it is associated. 

Diagnosis. — This is not difficult, provided that attention be directed to 
the throat ; but the physician often fails to discover it at his first visit from 
neglecting to examine this part. In many cases the local symptoms are not 



758 CATARRHAL PHARYNGITIS. 

well marked, and in the absence of these the febrile reaction may at first be 
referred to some other cause than the true one. Inspection not only reveals 
the presence of inflammation, but enables us to determine whether it be 
simple pharyngitis or diphtheritic or ulcerative. In some instances simple 
pharyngitis resembles the diphtheritic, from the presence of confervoid 
growths upon the inflamed surface, usually the Leptothrix buccalis. The 
diff"erential diagnosis is based on the easy removal and soft pultaceous charac- 
ter of the confervae and the appearance under the microscrope. 

Treatment. — 3IUd cases of simple pharyngitis require little treatment. 
With moderate counter-irritation over the throat and the use of laxative med- 
icines the inflammation soon subsides. The oleum camphoratum may be 
occasionally rubbed over the throat and retained upon it by flannel. The 
eff"ect is increased by the application, once or twice daily, of mustard or tinc- 
ture of iodine, or by adding to the liniment one-fourth or one-third of its 
quantity of turpentine. 

Some children seem to be most relieved by a muslin compress frequently 
wrung out of cool water or a light India-rubber bag containing ice. Fre- 
quently rubbing the neck with warm oil or camphorated oil and binding upon 
it a rind of salt bacon are popular modes of treatment, and no doubt are pro- 
ductive of benefit. 

In the severe forms of this inflammation, occurring independently of any 
other disease, more active measures are sometimes required. 

If there be stupor or restlessness, with unusual heat of head, and start- 
ing or twitching of the limbs which threatens convulsions, two to five grains 
of the bromide of potassium given every two or three hours produce a calm- 
ative eff"ect. 

Diaphoretic and sometimes cardiac sedatives are also indicated, such as 
liquor ammonias acetatis, spiritus aetheris nitrosi, ipecacuanha, and aconite. 
Medicines of this kind may be variously combined according to the age and 
condition of the patient and the severity of the disease. 

As the symptoms abate the intervals between the doses may be 
increased. 

In cases attended by much tenderness and dysphagia great relief is often 
obtained by hot poultices frequently applied over the neck. 

Topical treatment of the pharynx is recommended by most authors. 
Rilliet and Barthez use for this purpose nitrate of silver or powdered 
alum. The former has been most employed by physicians. It may be 
applied in the proportion of ten grains to the ounce two or three times 
daily. I prefer the following mixture, used with the hand-atomizer every 
hour to two hours : 



. Cocaini muriat., 


gr. 


Glyceriti acidi tannici, 


5J; 


Sodii hiborat., 


5J; 


Ammon. cbloridi. 


.^j; 


Glycerinse, 


.^j; 


Aquae, 


^v. 



Misce. 

This can of course be used as a gargle by those old enough, or more con- 
tinuously by the steam-atomizer. 

The treatment of secondary pharyngitis will be described in connection 
with the treatment of the diseases which it complicates. Suffice it here to 
say that this form of inflammation must not be treated by those depressing 
remedies which may be useful in cases of idiopathic pharyngitis. 



PERIPHARYNGEAL ABSCESS. 759 



Peripharyngeal Abscess. 

Every practitioner should bear in mind the fact that an abscess occasion- 
ally forms between the pharynx and vertebral column (retropharyngeal) or 
upon the side of the pharynx in the submucous connective tissue. This con- 
stitutes a disease which is likely to be fatal, but which can ordinarily be 
promptly relieved by the surgeon. 

Yet if we look over the records of peripharyngeal abscess we shall see 
that in a large proportion of fatal cases the disease was supposed to be some- 
thing else, and so treated until its nature was revealed by post-mortem exam- 
ination. The most complete monograph on this malady with which I am 
acquainted was published by Dr. Allen' of this city, under the title of 
" Retropharyngeal Abscess." To this paper I am largely indebted for the 
facts contained in this article. 

Age ; Causes. — This abscess may occur at any age, but it is most com- 
mon in infancy and childhood. It is more frequent in the first two years of 
life than at any other period. Of the cases collated by Dr. Allen in which 
the age is stated, 20 were under ten years and 21 over this age. The abscess 
occurs in some patients from caries of the vertebral column, and in others 
from inflammation developed in the connective tissue or small lymphatic 
glands lying immediately outside the pharynx, or from a catarrhal pharyn- 
gitis. Whichever the cause, there is usually a scrofulous or reduced state 
of system. 

Writers describe two kinds of peripharyngeal abscess, the primary and 
secondary. This distinction is based on the fact whether or not the inflam- 
mation which leads to the abscess be dependent on an antecedent patholog- 
ical state. 

In the primary form the cause is usually atmospheric, or it is some irri- 
tating substance which has been swallowed, and which, lodging in the 
pharynx, produces phlegmonous pharyngitis. 

The cause is mentioned in 20 cases of the primary form, collated by Dr. 
Allen, as follows : exposure to cold, 10 cases ; lodgment of bone in pharynx, 
8 cases ; blow with a fencing-foil, 1 case. In the last case the button of a 
fencing-foil passed through the right nostril into the pharynx. 

The secondar}^ form occasionally occurs after measles and scarlet fever. 
The inflammation of the pharynx common in those diseases extends to the 
subjacent connective tissue, and, aided by the dyscrasia of the patient, becomes 
suppurative. Such cases have been observed by Rilliet and Barthez. The 
most common cause of the secondary form is, however, caries occurring in 
the cervical vertebrae. 

When thus occurring it is similar, both as regards cause and nature, to 
lumbar abscess. It would follow the same chronic course, and would prop- 
erly be described in connection with it, were it not for its proximity to the 
air-passages, which renders the symptoms so urgent and dangerous. In a few 
recorded cases the abscess was a sequel of erysipelas. In 19 cases of second- 
ary abscess in Dr. Allen's collection the cause is assigned as follows : erysip- 
elas of face, 2 ; inflammation following a fall upon the inferior maxilla, 1 ; 
after cerebritis, 1 ; syphilis, 4 ; caries of the cervical vertebrae, 6 ; scrofula, 5. 

The plausible opinion is expressed by Mr. Fleming^ that the suppuration 
begins in a large proportion of cases in the small lymphatic glands which lie 
in the connective tissue external to the pharynx. The late Prof. George T. 
Elliot^ has recorded the case of an infant of seven months in whom peri- 
pharyngeal abscess immediately followed and was apparently due to parotiditis. 



^ N. Y. Jour, of Med., for Xovember. 1851. 

- Dublin Jour, of Med. Sci., vol. xviii. ^ Obstet. Clinic N. Y. 



760 • PERIPHARYNGEAL ABSCESS. 

In rare instances the abscess, or the local disease which leads to it, appears 
to exist from birth. Thus Dr. E. 0. Hocken relates ^ the history of an infant 
which died at the age of nine weeks. It had always, when taking the breast, 
thrown back its head as if nearly suffocated. The walls of the abscess 
were thick and firm, described by the writer as cartilaginous. Occasionally 
there is no apparent cause of the abscess except the strumous or cachectic 
state. 

Anatomical Characters. — The seat of the abscess is not the same in 
all cases. The swelling can ordinarily be seen on examining the fauces, but 
occasionally it is so low as to be really perioesophageal, and therefore invis- 
ible. The size of the abscess varies : sometimes it is large, pressing inward 
the wall of the pharynx even against the velum palati and into the posterior 
nares, if the abscess have a high location, or if lower against the larynx, so 
as to embarrass respiration. Sometimes the abscess is so large or has such 
lateral extension that there is external swelling along the side of the neck. 
In a few cases on record the pus, instead of being discharged into the pharynx, 
made its way down the neck between the muscles and the connective tissue 
to the pleural cavity, which it entered, producing fatal pleuritis. 

The walls of the abscess have been found in a different state in different 
eases. Sometimes the sac at the projecting point is so thin that it seems as 
if there might have been a spontaneous cure could life have been preserved 
a few hours longer. In other cases the sac is so thick and firm that its rup- 
ture for many days would be impossible. 

Symptoms. — The precursory symptoms differ in different cases according 
to the nature of the cause, whether it be phlegmonous pharyngitis or simply 
adenitis or vertebral caries. If the abscess proceed from caries, it is preceded 
by deep-seated pain, greatly increased by movements of the head, and prob- 
ably preceded also by induration along the sides of the vertebrae. 

The patient with this disease is restless, his mouth hot and dry, tongue 
furred, deglutition more or less difficult. Sometimes after suppuration has 
occurred there are alternations of rigors and fever. The symptoms indicate 
approximately the seat of the inflammation, but on examination we do not 
find that degree of redness of the mucous surface which we had been led to 
expect. The tissues which are chiefly involved in the inflammation, being 
submucous, are hidden from view. We observe redness of the pharynx, but 
it is disproportionate to the intensity of the symptoms. Some patients fre- 
quently experience a chilly sensation through the entire period of the abscess, 
though greater at one time than -at another, and occasionally convulsions 
occur, especially in young infants. In ordinary cases embarrassment of res- 
piration begins early, and is the cause of the chief danger. It becomes more 
and more marked as the abscess increases. It is noticed both during inspi- 
ration and expiration. The dysphagia also increases, sometimes to such a 
degree that drinks are taken with difficulty and solid food refused. The 
respiratory symptoms bear considerable resemblance to those in protracted 
laryngitis, for which this disease has been mistaken. While the respiration 
becomes impeded or whistling, the voice is also feeble or indistinct from the 
pressure of the tumor. 

But the symptoms described above are not all present in every case. 
They vary according to the size and location of the abscess, whether it be 
high or low, posterior or lateral. I have met the disease in a child old enough 
to make known the subjective symptoms, in whom there was little or no dys- 
phagia ; and others report similar cases. When the tumor has attained such 
a size that it produces well-marked symptoms and jeopardizes the life of the 
patient, it or a part of it can ordinarily be seen on depressing the tongue, 
^ Prov. Med. and Sury. Jour., 1842. 



SY3IPT0MS—D UBA TION. 76 1 

but usually its location and condition can be better ascertained by explora- 
tion with the finger. The dyspnoea increases as the abscess enlarges, and 
after a time, unless it burst spontaneously or be opened by the surgeon, 
imperfect oxygenation of the blood results. In some patients paroxysms 
of dyspnoea occur, so as to threaten immediate suffocation ; coughing or 
attempts to swallow induce these paroxysms, and the patient is forced to 
remain in an erect or semi-erect posture ; the tongue is protruded, the liQad 
thrown back, the pulse is frequent and rapid, the limbs become livid and cool, 
and finally death results from dyspnoea. Occasionally, when death seems 
inevitable, the abscess breaks during the struggles of the child and the 
patient is restored to health. In rare cases the result is diiferent. The 
trachea and bronchial tubes are deluged by the purulent discharge and imme- 
diate suffocation occurs. The following was an example: In May, 1871, a 
boy two years and five months old, who had the symptoms of an abscess for 
three months, was brought to the class at Bellevue. The head was carried 
on one side, its rotation caused pain, and a laryngeal rale accompanied respi- 
ration. The upper part of the tumor could be detected by the finger, but on 
account of its low location it was impossible to open it with the bistoury. 
The temperature was 103°, pulse 156. The case remained under observa- 
tion, but in a few days the dyspnoea suddenly became so urgent that death 
was imminent, when the attending physician of the class, Dr. Swezey, broke 
the abscess with his finger and pus was ejected on the floor ; death, however, 
occurred almost immediately. 

A correct appreciation of the symptoms and nature of peripharyngeal 
abscess will be best obtained by relating a case. I select the following from 
the Trans, of the Land. Pathol. Soc, Oct. 20, 18-16 : A female infant died at 
the age of seven months, having had difiicult breathing three weeks and 
extreme dyspnoea during the last days of life. The dyspnoea was constant, 
and was aggravated by mental excitement, by movements of the body, and 
by exposure to cold. During the paroxysms a peculiar croupy sound accom- 
panied inspiration. There was no dysphagia through the entire sickness, 
and death occurred from apnoea. The sac of the abscess was of the size 
of a pigeon's egg, and was situated between the upper cervical vertebrae and 
the back of the pharynx. The abscess was flattened in front, so as not to 
cause any decided prominence of the wall of the pharynx. From the sac a 
second small cyst extended forward, forming a nipple-like swelling in the 
pharynx which completely closed the orifice of the glottis. Its aperture of 
communication with the body of the abscess admitted the point of the little 
finger, and the whole swelling was freely movable and perfectly translucent 
at its extremities and sides. The abscess might have been easily punctured, 
with probably the preservation of life. 

The DURATION of this malady is very different, according to the inflam- 
mation, the rapidity with which the abscess enlarges, and the direction 
which it points. A lateral or downward extension is not so immediately 
dangerous to life as the anterior. 

The time when the abscess begins to form cannot be precisely ascertained, 
and most writers in determining its duration compute from the first appear- 
ance of symptoms which are referable to the pharynx. Dr. J. Byrne ^ 
relates a fatal case in which the disease had apparently continued only about 
one week. The patient was an infant one year old, and its death was from 
apnoea. The abscess was large, extending from the base of the skull to the 
thorax and pressing both on the larynx and trachea. M. Besserer^ gives the 
history of an infant four months old who died in the same way after thir- 
teen days. An infant nine months old, whose case was published by Dr. 

^ Amer. Jour, of Med. Sci., 1838. ^ Archiv. gen. de. Med., 1840. 



762 PERIPHARYNGEAL ABSCESS. 

W. C. Worthington/ lived nine days. The abscess occurred from exposure 
to cold ; the patient was treated for croup and died from suffocation. The 
anterior wall of the abscess was very thin. In two cases treated by me the 
symptoms indicated a continuance of the disease from two to four weeks, 
and in a third case four months. A fourth case is interesting on account 
of the short duration of the severe symptoms. The following is the record 

of it : M. E , aged seven months, female, nursing, inmate of the New 

York Foundling Asylum, was observed to have difficult breathing for the 
first time on March 28, 1875. Since about March 8th some swelling had been 
noticed along the side of the neck, but it gave rise to no marked symptoms, 
and she had not seemed ill till the obstruction in the respiration commenced. 
At my visit on the evening of the 28th the infant was pointed out to me as 
in a dying condition. She was lying in a state of stupor, pallid and gasping 
for breath, with a temperature of 103°, and very feeble pulse, numbering 
about 200 per minute. On carrying the finger into the throat an abscess 
could be readily detected, situated in the walls of the pharynx on the left 
side posteriorly. This was easily opened by a curved bistoury, around 
which adhesive plaster was wound to within half an inch of the point. The 
breathing immediately began to improve. On the following day the infant 
was playing in the mother's lap, with a pulse of 140, but a normal tempera- 
ture. With the use of cod-liver oil and the syrup of the iodide of iron its 
health was soon fully restored. In a fifth case the abscess was ruptured by 
the finger, and in a sixth it was opened by the lancet. All these patients 
recovered. 

When the abscess grows slowly and presses lightly on the air-passages 
the case may continue for months. Such a one was observed by the late 
Professor Willard Parker (Allin). This infant was one year old ; it suffered 
from pharyngeal symptoms nine months, was treated for tonsillitis, and 
death occurred as usual from apnoea. The abscess was two inches long, and 
there was no disease of the vertebrae. The same surgeon saved the life 
of another patient four years old, in whom the disease was protracted, by 
puncturing the abscess ; and the late Professor Post also treated successfully 
a case which had continued three months (Allin). 

Diagnosis. — The diagnosis of retropharyngeal abscess is ordinarily easy, 
provided that the physician examine carefully and bear in mind the occasional 
occurrence of such an abscess. In a large proportion, however, of the 
recorded fatal cases the true nature of the disease was not recognized during 
life. Especially is the diagnosis difficult when the cerebro-spinal system is 
early implicated and symptoms arise which divert attention from the throat 
to the brain. 

The maladies for which peripharyngeal abscess is most frequently mis- 
taken are laryngitis and simple but severe pharyngitis. From laryngitis, for 
which it has been most frequently mistaken, it may be distinguished by the 
dysphagia and by the character of the initial symptoms. In laryngitis there 
is usually the peculiar cough from the first or very early, while in abscess 
there is an initial period of several days, or even weeks, before respiration is 
materially affected. This is the period of inflammation which precedes sup- 
puration. 

In abscess pressure of the larynx backward is badly tolerated, greatly 
increasing the dyspnoea, while in pharyngitis and croup this effect is not so 
marked. In abscess the horizontal position aggravates the dyspnoea, but not 
in pharyngitis and croup. The character of the voice also aids in diagnosti- 
cating an abscess from laryngitis, since in the former it is usually nasal, and 
in the latter hoarse and whispering. But the decisive test is afforded by 
^ Prov. Med. and Surg. Jour., 1842. 



CESOPHAGITIS. 763 

inspection and digital exploration. The tumor is seen — or, if situated 
too low to be seen, is felt — upon the walls of the pharynx. 

If the symptoms of abscess are masked by those arising from the cere- 
bro-spinal system, as by convulsions, the priority of the pharyngeal symp- 
toms aids in determining the true disease. 

In a case of suspected abscess the physician should not only carefully 
inspect the fauces, but should also employ digital examination. The finger 
will often detect fluctuation before the abscess is apparent to the eye. 

Prognosis. — With proper treatment the result is usually favorable, but 
if the disease be not recognized many die. In Dr. Allin's cases, of those 
under the age of twelve years, 9 died, while 10 recovered by the opening 
of the abscess by the lancet, trocar, or finger, and 1' by its spontaneous 
rupture. 

If the abscess be due to disease of the spinal column, death may occur 
immediately after the sac is opened, the caries of the intervertebral carti- 
lages producing, according to Dr. Allin, dislocation of the vertebrae. Death 
may also occur, though rarely, from pleuritis, in consequence of the bursting 
of the abscess into the pleural cavity. Even in caries, if the sac be properly 
opened and if need be reopened, and the head supported by suitable appara- 
tus, recovery is possible, as in a case treated by Prof. Post. 

Treatment. — The proper treatment of peripharyngeal abscess is simple, 
consisting in breaking or puncturing the sac by the finger, the lancet, bis- 
toury, or pharyngotome. Each method has been successfully employed. In 
the majority of cases the proper way to open the abscess is by the ordinary 
curved scalpel or bistoury, which should be covered by a strip of adhesive 
plaster to within half an inch of the point. If the abscess be postpharyn- 
geal it should be opened in the median line. A single incision suffices to 
evacuate the pus. If the abscess point or be elastic, there is little danger of 
wounding any important vessel or producing dangerous hemorrhage if the 
operation be properly performed. It may be necessary to open the abscess 
more than once, as in a case reported by Dr. Post and another which I saw 
with Dr. Livingston of this city. In certain cases, when the knife cannot be 
readily employed, the abscess may be opened by pressure with the finger-nail 
or the edge of a teaspoon. 

Patients with this disease ordinarily require constitutional treatment, 
especially the use of tonics, ferruginous and vegetable. The citrate of iron 
and quinine, the citrate of iron and ammonium, and in strumous cases the 
syrup of the iodide of iron with cod-liver oil, are eligible preparations. 
Nutritious diet and often alcoholic stimulants are required. 

CESOPHAGITIS. 

Disease of the oesophagus in infancy and childhood is comparatively rare, 
inflammation being the most frequent affection of this portion of the diges- 
tive tube in these periods, and, indeed, the only one which claims attention. 
It is most common in infants under the age of three or four months who are 
deprived of the breast-milk and are given a diet which is with difficulty 
digested, and perhaps taken too hot or too cold. It is therefore most com- 
mon in foundling hospitals. I have frequently observed it in the Infants' 
Hospital and the Nursery and Child's Hospital of this city, chiefly at the 
autopsies of bottle-fed infants under the age of six months, whose symptoms 
had indicated disease or derangement of the digestive function. Many of 
them had diarrhoea and died in a state of emaciation. (Esophagitis in these 
cases was associated with simple or gangrenous stomatitis, thrush, or with gas- 
tritis or entero-colitis. Sometimes all these inflammations coexisted. In a 



764 (ESOPHAGITIS. 

few cases the confervoid growth of thrush had extended from the mouth to 
the oesophagus. It occurred in small hemispherical masses scarcely as large 
as a pin's head. Swallowing corrosive or strongly irritating substances, as 
the acids or alkalies, is an occasional cause of oesophagitis, the irritant at the 
same time producing stomatitis and gastritis. 

Anatomical Characters. — The inflamed surface sometimes presents a 
uniformly injected appearance. Usually, however, there is greater intensity 
of the inflammation in streaks or patches than over the surface generally. 
I have frequently observed at autopsies a greater degree of inflammation in 
the lower than upper half of the oesophagus, even when the infant had sto- 
matitis at the time of death. 

Qj]sophagitis occurring from faulty regimen or antihygienic conditions is 
not accompanied by as much thickening of the walls of the tube as often 
occurs in some other portions of the digestive canal; as, for example, in the 
colon. Diphtheritic inflammation of the oesophagus is accompanied by so 
great infiltration of the mucous membrane and underlying connective tissue 
that I have seen the oesophageal walls three or four times the normal 
thickness. 

Occasionally ulcerations of the oesophageal mucous membrane are observed 
in the lower part of the tube, and Billard describes the ulcerative form of 
oesophagitis. At the first autopsies at which I observed these ulcers I sup- 
posed that they were pathological and indicated a severe grade of inflamma- 
tion ; but a more extended observation has convinced me that they are usu- 
ally post-mortem, and are not at all dependent on inflammation of the oesoph- 
agus. The solvent power of the Agastric juice not only causes ulceration 
in the stomach, but, entering the oesophagus, may and not infrequently does 
produce a solvent action on the mucous tissue there in the cadaver. At the 
meeting of the London Pathological Society, March 4, 1852, Dr. Graily Hewitt 
presented a specimen in which the gastric juice had not only eaten entirely 
through the coats of the oesophagus an inch above the stomach, but had even 
attacked the left lung. Over the age of six months inflammation of the 
oesophagus is rare. 

The symptoms of oesophagitis in young and emaciated infants, in whom 
it ordinarily occurs, are not well pronounced. Pain in deglutition or tender- 
ness on pressure over the oesophagus, if present in these infants, is ordinarily 
not appreciable, nor have they seemed to me to vomit oftener than other 
infants of this class who suff"ered from indigestion and gastro-enteritis with- 
out oesophagitis. It is therefore difficult to diagnosticate oesophagitis in them. 
It is, according to my observation, oftener present than absent in spoon-fed 
infants of three months or under who have persistent stomatitis and entero- 
colitis. 

Treatment. — In the oesophagitis of foundlings and ill-nourished infants, 
which arises, as has been stated, from faulty regimen, no treatment is required 
apart from that designed to relieve the stomatitis or entero-colitis with which 
it occurs. Attention must be directed mainly to the diet and hygienic man- 
agement. The remedial measures proper for such patients are more fully 
detailed in our remarks on entero-colitis. (Esophagitis produced by swallow- 
ing corrosive or highly irritating substances requires the same treatment as 
in the adult — to wit, poultices, demulcent drinks, etc. 



INDIGESTION. 765 



CHAPTER Y. 

INDIGESTION, CONGESTION OF STOMACH, GASTRITIS, FOLLICULAR 
GASTRITIS, DIPHTHERITIC GASTRITIS, GASTRO-MALACIA. 

Indigestion. 

Indigestion is more common during infancy than in any other period of 
life. While the digestive organs in the adult readily assimilate a great 
variety of food, it is necessary for the well-being of the infant that its diet 
be simple and carefully prepared. Departure from this rule leads to indiges- 
tion and ulterior diseases. 

After the age of two years a mixed diet is readily assimilated, the digestive 
function is less frequently disordered, and indigestion presents few peculiarities 
to distinguish it from that of the adult. 

Indigestion in some children is habitual ; in others the digestive process is 
ordinarily well performed, but from some temporary derangement of system 
or error of diet an acute attack of indigestion occurs. Hence, two forms of 
this ailment may be described ; first, acute, referring to temporary attacks ; 
secondly, chronic, referring to the habitual state. 

Causes. — The causes of indigestion are twofold : first, the condition of 
the digestive function independently of the aliment; secondly, the unwhole- 
some or improper character of the ingesta. Anything which lowers the vital 
powers may be a predisposing cause of indigestion by impairing the function 
of the organs which assimilate the food. Impure air and personal uncleanli- 
ness, protracted hot weather, and previous disease are among the common 
predisposing causes. The strong country child can thrive upon a diet which, 
given to the more feeble child of the city, would produce deleterious results. 
During the summer months it often happens that an infant in the city can- 
not digest properly any food given to it except the mother's milk ; and from 
this results much of the infantile sickness and mortality which make this 
season of the year much dreaded by parents. There is a natural difference 
in children as regards liability to disordered digestion. Some do well upon a 
diet which, given to others similarly situated, occasions vomiting, gastralgia, 
and flatulence. 

In the majority of cases of indigestion, however, the fault does not exist 
in the child. It is fed too often or irregularly or upon a diet that is unwhole- 
some or indigestible. It is well known that the milk of the mother or the 
wet-nurse is liable to changes which render it for the time unsuitable for the 
infant. Her food may be of such a quality, or her mind so excited, or some 
function of her system so disordered, as to effect a temporary change in the 
constitution of her milk. The occurrence of the catamenia or of gestation 
in mothers who are suckling not infrequently produces this unfavorable 
result. 

Indigestion is most common in those infants who, deprived of the 
mother's milk, are entrusted to wet-nurses or fed from the bottle. The 
milk of the wet-nurse, from not agreeing with the age of the infant, from 
irregularity in her mode of life, from the acescent nature of her food, or from 
other causes which are not appreciable, may disagree with the infant and be 
imperfectly digested. 

The most common cause of indigestion in the infant is artificial feeding. 



766 INDIGESTION, CONGESTION OF THE STOMACH, ETC 

This, in the cities, is productive of a great amount of gastric and intestinal 
derangement and disease. The younger the infant the less frequently does it 
thrive if brought up by hand. 

Whatever care may be bestowed in the preparation of its food, whether 
cow's or goat's milk or farinaceous substances be used, there is seldom that 
healthy nutrition which is observed in infants who receive the breast-milk. 
The " swill milk " in common use among the poor families of this city is 
totally unfit for the feeding of infants, and is apt to cause flatulence, acidity, 
and indigestion. Acute indigestion occurs in children of any age from food 
unsuitable in quality or quantity, which produces gastralgia and other symp- 
toms to be detailed hereafter. Those who suffer habitually from malassimila- 
tion are especially liable to such acute attacks. 

In the period of childhood chronic indigestion is much less frequent than 
in infancy, but children are perhaps more subject than infants to the acute 
form. This is induced by ingesta taken in too large quantity or of a kind 
which is with difficulty digested. Cherries, currants, raisins, and the paren- 
chyma of oranges and lemons, dried fruits, and confectionery, which are so 
often heedlessly given to children, are common causes of acute attacks of 
indigestion. These substances, being but partially digested or not at all. and 
sometimes accumulating for days in the stomach or intestines, may lead to a 
very serious and dangerous condition. 

Symptoms. — Before describing the symptoms of indigestion I wish to 
direct attention to one form of vomiting in young infants which is usually 
attributed to indigestion by the young practitioner, but which really has no 
pathological significance. I refer to vomiting or regurgitation of milk in 
hearty and well-nourished infants, resulting from too frequent nursing or 
over-nursing. It occurs without previous nausea and with little effort. The 
relatively small size of the stomach in young infants, its position more verti- 
cal than in older children, and the little development of the fundus, which is 
the proper receptacle of the milk, favor this regurgitation. The milk that is 
ejected is unchanged if it be returned immediately after the nursing, but if 
some moments have elapsed the casein is more or less coagulated. Little 
harm is done by this loss of nutriment if the infant appear well and thriving. 
It is, indeed, salutary, for if the food that is in excess of what is wanted, and 
in excess of what can be digested, be retained, it undergoes fermentation, 
and, becoming an irritant, causes indigestion and diarrhoea. The remedy 
consists in less frequent or less prolonged nursing, and allowing the infant to 
lie quietly in the crib after each nursing. 

But vomiting is a symptom that should always arrest attention and its 
cause be ascertained. If the child cease to grow and lose its vivacity, the 
vomiting has pathological significance. Frequent vomiting, without other 
marked symptoms referable to the digestive apparatus, and with evident loss 
of flesh and strength, is in most cases a symptom of gastric indigestion or 
of incipient meningitis. The presence of mucus in the ejected matter, 
eructation of gas, and the apparent absence of headache and of other menin- 
geal symptoms apart from the vomiting, aid in establishing the diagnosis of 
gastric indigestion. 

With these preliminary remarks we will proceed to consider the symptoms, 
first of habitual, and next of acute temporary, indigestion. 

The nursing infant, if the milk continually disagree with it, is fretful. 
It has a discontented aspect ; it seldom smiles, and is not amused by playthings 
or is only amused for a short time. Its features are pallid and bear the appear- 
ance of faulty nutrition. Its body and limbs are more or less wasted or are 
soft and flabby. Vomiting is frequently present, and sometimes a large mass 
or masses of casein are ejected which have evidently lain a considerable time 



INDIGESTION. 767 

in the stomach. The bowels may be constipated or loose and the evacuations 
are unhealthy. This state of the infant, continuing, prevents the necessary 
rest of the mother, and may affect unfavorably her health, so as to reduce the 
quantity of her milk, or render it still more unwholesome. 

In habitual indigestion of young children fermentation of the food occurs 
to a great extent, instead of normal digestion, and the fermentation results 
in the production of acids. Whatever irritates the gastro-intestinal surface 
causes an increased secretion of mucus, and it is believed that the mucus, 
since it is alkaline, prevents to a great extent the digestive action of the 
pepsin, which requires an acid medium, so that lactic, butyric, and the fatty 
acids result. This aaid fermentation, beginning in the stomach, extends to the 
intestines as the food is carried downward. Hence the acid breath, sour- 
smelling ejecta, fetid stools, flatulence, and colicky pains, indicating both 
gastric and intestinal dyspepsia, so common in young, improperly-fed infants. 

Habitual indigestion is, as might be expected, more common and severe 
in artificially fed infants than in those at the breast, and it is more likely to 
result in gastro-intestinal catarrh. In rural localities, where children are 
much of the time in the open air, have good constitutions, active digestion,, 
and fresh food, dyspepsia is comparatively rare, but in large cities, in which 
the conditions of life are so different, its occurrence is common. Gross care- 
lessness in the feeding, and ignorance on the part of mothers of the dietetic 
requirements of young children contribute greatly to its frequency. 

Attacks of acute indigestion not infrequently occur from careless and 
improper feeding in children who are habitually dyspeptic, as well as in those 
whose digestive function is usually well performed. In these acute attacks 
young children, especially infants, often suffer much from colicky pains, 
gastralgia, or enteralgia. Their countenance indicates suffering ; they utter 
sharp cries ; their thighs are flexed over the at)domen and moved from side to 
side. Warm spirituous lotions, friction or gentle pressure upon the abdomen, 
give some relief, especially if they be attended by the expulsion of flatus. 
Vomiting or an evacuation of the bowels commonly removes the offending 
substance, and the pain subsides. 

Attacks of acute indigestion come on suddenly, and occasionally are so 
severe that they produce dangerous symptoms, as eclampsia. Apart from 
pain or a sensation of weight or fulness in the abdomen, symptoms of a reflex 
character frequently occur, such as headache, drowsiness or languor, sudden 
twitching of the limbs premonitory of convulsions, and even severe or repeated 
convulsions. One of the most severe attacks of eclampsia which I have seen 
occurred in a boy of eight or ten years, induced by swallowing the pulp of 
oranges which he had been in the habit of eating, and which had accumulated 
in the stomach and intestines. The expulsion of the offending substance 
gave immediate relief. In some children with acute indigestion the pulse is 
notably accelerated, the face flushed, the surface hot, and the temperature 
elevated two or three degrees above normal. 

As the child advances in years and becomes stronger its digestive func- 
tion is more active, a greater variety of food can be assimilated, and indi- 
gestion, whether temporary or habitual, is less frequent than in the first years 
of life. 

Prognosis. — Indigestion in the adult, when not due to organic disease, 
involves little danger to life, but in infancy its consequences are often serious. 
Habitual indigestion in the infant, whether due to the bad quality of the 
breast-milk or to artificial feeding, is liable to cause inflammation of the buccal, 
oesophageal, gastric, or intestinal mucous membrane, and in some patients of 
two or more of these divisions of the intestinal tract. Thus, especially in 
the warm months, the acid products of indigestion often cause a dangerous 



768 INDIGESTION, CONGESTION OF THE STOMACH, ETC. 

catarrhal inflammation, accompanied by vomiting and frequent stools. Many 
cases of atrophy in infants, characterized by arrested growth and gradual loss 
of flesh and strength, till perhaps the features have a sunken and senile 
appearance from the waste and the skin lies in wrinkles, originate in habitual 
indigestion. Henoch points out the frequency of gastro-malacia in infants 
who have safi"ered from severe dyspepsia accompanied by the abundant pro- 
duction of acids. The softening of the stomach is believed to be largely, if 
not entirely, cadaveric, the result of post-mortem digestion from the presence 
of pepsin and the acids of fermentation. The gastric mucous membrane can 
be readily scraped away by the nail, and it presents a gelatiniform appearance. 
Sometimes even the stomach is perforated and the adjacent organs are acted 
on by the corrosive liquids. 

If the dyspepsia have not continued so long as to cause inflammatory 
complications, prompt recovery is probable by the use of suitable food and 
corrective medicines. If such complications be present, recovery can only 
be gradual. 

Diagnosis. — Habitual indigestion does not usually continue long without 
the occurrence of more or less gastro-intestinal catarrh. The poor nutrition 
and appetite, the unhealthy, flatulent stools containing mucus, the vomiting 
and occasional colick}^ pains, are symptoms which plainly indicate a dyspeptic 
origin. Attacks of acute indigestion are also easily diagnosticated, in most 
instances by the sudden occurrence of the symptoms, such as vomiting, pain 
in the abdomen, or a sensation of fulness, eructation of gas, etc., and the 
speedy subsidence of symptoms when the cause is removed. But sometimes, 
especially in children over the age of two or three years, the symptoms may 
so closely resemble those of other acute diseases that a careful examination 
is required in order to make a clear and correct discrimination. Thus I have 
related above the histor}' of a case in which the high temperature and expira- 
tory moan closely resembled those of pneumonia, but the symptoms quickly 
abated on the expulsion of a considerable quantity of orange-pulp. An 
attack of acute indigestion, attended by vomiting, rapid pulse, elevated 
temperature, with perhaps some erythema, may be mistaken for the com- 
mencement of one of the febrile diseases to which children are so liable. 
If on examination of the fauces no redness of the throat be observed, scarlet 
fever and diphtheria can be excluded. By a free evacuation of the bowels 
the symptoms abate and the attack ends, so that if there were any doubt in 
the diagnosis it is soon dispelled. 

When eclampsia results from an attack of acute indigestion, the physi- 
cian is often compelled to act promptly without a clear diagnosis, but the 
result of treatment soon renders the nature of the attack apparent. 

Treatment, — The first indication in treatment is obviously the removal 
of the cause. In acute indigestion, when there is reason to believe that there 
is some off"ending substance in the stomach or intestines, if the symptoms 
occur soon after the substance is taken an emetic may be administered, and 
ipecacuanha, in syrup or powder, is a safe and usually efficient remedy. If 
several hours have elapsed a purgative should be given, as castor oil, either 
alone or in combination with syrup of rhubarb, or an enema of glycerin and 
water may be employed. 

If the symptoms be urgent, especially if convulsions be threatened, we 
should not wait for the slow action of a purgative, but should resort at once 
to an enema to open the bowels. Sometimes the pain in acute indigestion 
is such as to require immediate treatment. I have found in such cases five- 
to twenty-drop doses, according to the age, of aniseed cordial, made as 
directed in the National Formulary, a useful remedy. In the infant there 
is often an excess of acid in the stomach and intestines, which is best treated 



IXDIGESTIOX. 769 

by alkaline remedies, as lime-water in combination with the opiate. The fol- 
lowing mixture will be found useful in sucli cases : 

R. Tinct. opii deodorat., or liq. opii coraposit. (SquibbsJ, gtt. xij ; 

Magnes. calcinat.. gr. xij-xxiv ; 

Sacch. alb., 5J ; 

Aq. anisi, ^iss. Misce. 

Dose : The bottle being first shaken, one teaspoonful every two hours to a child a year 
old until relief of pain. If there be much pain, it is well to add a little chloro- 
form or Hoffman's anodyne to the mixture. 

Or the following mixture : 

R. Tinct. opii deodorat.. or liq. opii composit., gtt. xij ; 

Bismuth, subcarbonat., .^iss ; 

Syr. simplic. ^^ss; 

Aq. cinnamomi. 5J- Misce. 

Shake bottle thoroughly and give one teaspoonful to a child of one year. 

If in the acute indigestion of infants diarrhoea occur, the camphorated 
tincture of opium, in combination with chalk mixture, may be given, fifteen 
drops of the one to a teaspoonful of the other, or the above mixture of 
laudanum and bismuth may be employed. Infants whose diet consists 
largely of cow's or goats milk digest with most difiiculty the casein, which 
often passes the bowels in an imperfectly digested state, or it collects in a 
large and firm mass in the stomach, causing gastralgia and rendering the 
child fretful till it is vomited. I have elsewhere recommended, as important 
to prevent these attacks of acute dyspepsia, the use of the upper third of 
the milk, which contains less than the average casein. The addition of a 
little farinaceous food, as barley-water, to the nursing-bottle will sometimes 
produce the same effect by mechanically separating the particles of milk. 
Peptonized milk, as recommended in our remarks on the hygienic treatment 
of Intestinal Catarrh, will also be found useful in certain cases, and also the 
employment of a good preparation of pepsin at each feeding. 

In chronic indigestion the means of relief are different. They are two- 
fold : first, as regards change of diet ; secondly, measures to improve the 
digestive function. Spoon-fed infants, suffering from habitual indigestion, 
require the utmost care as regards the character of their food, its preparation, 
and the times of feeding. Often it is best, if practicable, to procure a wet- 
nurse, and sometimes removal to a more salubrious locality is followed at 
once by improvement in the digestive function. If the infant be already 
wet-nursed, the milk should be examined microscopically and otherwise, and 
inquiry should be instituted in reference to the health and diet of the wet- 
nurse. Sometimes a change of wet-nurse is advisable. (For facts and con- 
siderations bearing on this point the reader is referred to the chapters relating 
to regimen.) 

Children with chronic indigestion are occasionally much benefited by the 
moderate and judicious use of alcoholic stimulants. These should be given 
sparingly with their food, and should be discontinued as soon as the digestive 
function is fully restored. 31. Donne and some other French writers recom- 
mended the habitual use of wine for infants even in a state of health, but 
there are reasons, moral as well as physical, why alcoholic stimulants should 
only be used as medicines and not in a state of health. 

If the case be one of simple or uncomplicated indigestion, pepsin or 
lactopeptin of the shops and tonics may be employed. In many instances, 
however, especially in infancy, gastro-intestinal inflammation has supervened, 

49 




770 INDIGESTION, CONGESTION OF THE STOMACH, ETC. 

and in sucli cases tlios<3 remedies should be employed which exert a favor- 
able — or at least not an unfavorable — effect on the inflamed surface over 
which they pass. 

In habitual indigestion remedies are obviously required which increase 
the quantity of the digestive ferments. The following will be found a use- 
ful prescription in cases of indigestion in which gastro-intestinal catarrh has 
supervened : 

R. Acidi hydrochlorici dilut., 
Pepsini puri, in lamellis, 
Bismuth, subnitrat., 
Syr. siraplic, 

Aquse destillat., ^iij. Misce. 

Shake bottle, and give one teaspoonful before each feeding. 

The lactopeptin of the shops is also useful, and when diarrhoea accom- 
panies the indigestion the following may be prescribed : 

R. Bismuth, subnitrat., Siij 5 

Lactopeptin, ^ _ ^ij ; 

Pepsini puri, in lamellis, 5j. 

Give as much as goes on a five-cent-piece to a child of ten months before each feeding. 

If the stools continue frothy and offensive on account of the fermenta- 
tion the following will be found beneficial : 

R. Creasoti or acidi carbolici, gtt. ij ; 
Syr. simplic, .^ss ; 

Aqnse destillat., 5iss. Misce. 

Dose : One teaspoonful every two hours to a child of one year. 

In children over the age of three or four years the vegetable tonics are 
often useful, as quinine in half-grain or one-grain doses. Iron may also be 
given, especially the milder preparations, as the citrate, in anaemic cases. 

Among the useful vegetable stomachics and tonics may also be men- 
tioned the compound tincture of cinchona, compound tincture of gentian, 
infusion of columbo, fluid extract of columbo, and fluid extract of cinchona. 

If chronic indigestion be complicated with gastro-intestinal inflammation, 
subacute or chronic, for this is the form which is usually present, there are 
still certain tonics which may be advantageously administered. Columbo 
and the compound tincture of cinchona are often useful in these cases, and 
of the chalybeates wine of iron or the citrate of iron and ammonium or the 
liquor ferri nitratis may be safely administered. In most cases, however, 
change in the diet properly made will be found more useful than tonic and 
corrective medicines. 

Infants affected with diarrhoea from indigestion often improve under the 
use of powders consisting of equal parts of subnitrate of bismuth and lacto- 
peptin. An infant of three months can take three grains of each every three 
hours or before each feeding, or it may take three or four grains of the sub- 
nitrate of bismuth with half a grain of pure pepsin in scales. 

Dyspepsia often rapidly disappears by hygienic measures without the use 
of medicines, as by removal from the city to the country, outdoor exercise, 
or, if the patient be an infant, by being carried into the open air daily. In 
infants also marked improvement is often observed on the approach of the 
cool and bracing: weather of autumn and winter. 



GASTEITIS. 771 



Congestion of the Stomach. 



Passive congestion of the stomach is described among the diseases of this 
organ by Billard, but it is a pathological state of little importance in itself. 
It occurs in new-born infants, asphyxiated at birth and with difficulty resusci- 
tated. In these cases there is generally intense capillary congestion through- 
out the system. The mucous membrane of the stomach is injected, but not 
more than that of the mouth or intestines. If circulation and respiration be 
fully established, this injection of the capillaries subsides. No treatment 
is required, except measures to promote the circulatory and respiratory func- 
tions. In cyanosis and atelectasis there is often general congestion of the 
capillaries of the systemic circulatory system on account of the obstruc- 
tion to the flow of blood through the heart in the one disease and through 
the lungs in the other. There is in these cases passive congestion of the 
stomach, but not more than of other organs. 

Gastritis. 

Inflammation of the stomach, except when produced by the direct con- 
tact of some irritant, is rare in infancy and childhood, independently of dis- 
ease in some other portion of the intestinal tract. Cases have, however, been 
reported in which it was not known that any irritating ingesta had been taken, 
and in which a careful examination revealed a healthy or nearly healthy state 
of other portions of the digestive tube. The subjects were for the most part 
young infants. The following is an example related by Billard : 

An infant, four days old, remarkable for the color of his face and firm- 
ness of flesh, refused the breast and vomited yellow, acid matter. On the 
following day the vomiting had increased, the legs were oedematous, face pal- 
lid and pinched, respiration difficult, skin cold, pulse slow and irregular, and 
pressure on the epigastric region produced cries indicative of pain. 

Third day : general sinking ; face thin and expressive of great pain ; stools 
natural. 

Fourth and fifth days : condition the same. Death occurred on the sixth 
day, and the autopsy was made on the day following. 

AVith the exception of slight pneumonia no disease was discovered in 
any part of the system besides the stomach. The mucous membrane of this 
organ was intensely vascular near the cardiac orifice and along the lesser 
curvature. This part was also tumefied, and could be easily raised with the 
finger-nail. The remainder of the gastric surface was hypersemic, but to a 
less extent. 

This case is interesting as showing what may happen, though rarely. A 
nursing infant is seized with gastritis without apparently having taken any 
irritating ingesta and without other disease of the digestive apparatus. It 
is probable, however, that in cases like the above the cause, if ascertained, 
would be found in the ingesta ; perhaps drinks too hot, perhaps elements of 
colostrum or pathological elements in the milk, which might produce gastritis 
in young infants, in whom the mucous membrane is delicate and sensitive. 

Gastritis is not uncommon in infancy in connection with inflammation of 
the intestines. The latter inflammation is sometimes apparently subordinate 
to the former, and if such patients die the fatal result is due mainly to the gas- 
tric disease. The reverse is, however, the rule. The gastritis is ordinarily 
subordinate to the intestinal catarrh. 

Cause. — Gastritis, as I have observed it in infants, has been in most cases 
due in great part to the continued use of improper food — of food not suitable 
to the age of the child, and which was therefore with difficulty digested. 



772 INDIGESTION, CONGESTION OF THE STOMACH, ETC. 

Milk, acid or otherwise unwholesome, farinaceous substances, stale or of an 
inferior quality and not properly prepared, drinks too hot or too cold, may be 
specified among the causes. Therefore this disease is most common in bottle- 
fed infants, and is comparatively rare in those who receive abundant and 
wholesome breast-milk. Antihygienic agencies, apart from the diet, no doubt 
exert some influence in the production of gastritis, as they do of stomatitis. 
Uncleanliness and residence in damp and dark apartments or in an atmosphere 
loaded with noxious gases produce a condition of system which strongly pre- 
disposes to these inflammations, if, indeed, they may not be enumerated 
among the direct causes. 

Killiet and Barthez have called attention to the fact that certain medicinal 
substances given to children occasionally cause gastritis. They have observed 
this effect from the use of tartar emetic, kermes mineral, and croton oil. 
Gastritis occurring in this way may or may not be associated with inflamma- 
tion in contiguous portions of the digestive tube. Elsewhere I have related 
a case in which gastro-enteritis occurred in a child nine years old after having 
taken a considerable quantity of kerosene oil for spasmodic croup. 

Inflammation of the stomach is thought by some to accompany measles 
and scarlet fever during the eruptive period, but this opinion is probably 
incorrect. If it occur, it corresponds with the stomatitis and dermatitis of 
these diseases, and disappears as they subside. It is mild and accompanied 
by few symptoms. I have, as stated in the remarks on Scarlet Fever, exam- 
ined in certain instances the stomachs of those who have died during the 
eruptive period of these diseases, and found them free from any appreciable 
inflammatory lesion. 

Age. — From the records of about seventy cases of inflammatory disease 
of the digestive mucous membrane which I have preserved it appears that 
gastritis is not common over the age of six months. On the other hand, it 
is common in infants under the age of three months who are deprived of 
breast-milk. I have met it chiefly in foundlings fed with the bottle, and hav- 
ing at the same time entero-colitis, and often also stomatitis and oesophagitis. 
In these cases there is sometimes continuous or almost continuous injection 
and thickening of the mucous membrane, from the lip to near the pyloric 
orifice of the stomach, and even beyond this orifice in the intestines. 
The following is an example of gastritis as it frequently occurs in foundling 
institutions : 

Case. — E. W , female, two weeks old, was admitted into the New York 

Infant Asylum, August 24, 1865, anaemic and somewhat emaciated. She was in 
part wet-nursed and in part bottle-fed. The emaciation increased, and nearly 
the entire buccal cavity became covered with the confervoid growth of thrush. 
On September 4th diarrhoea commenced. Borax was used for the mouth and 
alkalies and astringents to check the diarrhoea, but without material improve- 
ment. 

The following was the record for September 7th : " Cries almost constantly, 
Avith feeble or whining voice; still has thrush; nurses and does not vomit; 
stools five or six daily, and green ; pulse 136, feeble." Death occurred Septem- 
ber 8th. 

Autopsy, SejAemher 9th. — Mouth and fauces not examined; mucous membrane 
of oesophagus vascular in its whole extent, with slight thickening, but without 
ulceration ; mucous membrane of stomach injected like that of the oesophagus, 
and somewhat thickened, except in its pyloric extremity, where the appearance 
was natural or nearly so; the color in the central part of the inflamed gastric 
membrane was deep red; no thrush was noticed, except on the buccal surface 
during life ; along the great curvature of the stomach were white flakes resem- 
bling those of thrush, but which were found by the microscope to consist mainly 
of oil-globules and epithelial cells, without the cryptogamic formation; mucous 
membrane of small intestines healthy in their whole extent, except slightly 



GASTRITIS. 773 

increased vascularity in a few places in the ileum ; mucous membrane of colon 
much injected throughout, except near the ileo-caecal valve, where the vascularity 
was slight ; in the transverse and descending colon the redness was pretty uni- 
form, and the membrane was thickened, but not ulcerated ; solitary glands and 
Peyer's patches moderately elevated. 

The observations of Valleix show how frequently gastritis is associated 
with severe attacks of thrush. In 23 of his cases of the latter disease in 
which the condition of the stomach was noted after death this organ pre- 
sented inflammatory lesions in 17, and in three others appearances which may 
or may not have been due to inflammation. 

Symptoms. — A difficulty exists in isolating and defining the symptoms of 
gastritis, from the fact that it commonly coexists with other inflammations 
of the digestive tube. Though we may never be able to diagnosticate this 
catarrh as certainly as we can croup or pneumonia, still there are symptoms 
which arise directly from the gastritis, and with care we may be able to dis- 
tinguish them from those symptoms which are due to other pathological 
states. 

If gastritis be acute, pain is present. In the above case from Billard, 
as well as in a case observed by myself and related under the head of Grel- 
atinous Softening, there were frequent cries, and the countenance indicated 
much suff"ering until the stage of collapse. If there be less intensity of 
inflammation and the disease be more protracted, as is ordinarily the case, the 
pain is not so severe, and it may be so slight as not to attract attention. 
Sometimes there is tenderness, so that pressure upon the epigastric region is 
badly tolerated. Vomiting is regarded as one of the most constant symp- 
toms. The infant after nursing seems in distress till the milk is returned, but 
it nurses with avidity in consequence of the^ thirst if it be not too exhausted 
or feeble. The dejections may be quite regular throughout the disease, as in 
the case from Billard. There is ordinarily, however, diarrhoea from the 
presence of entero-colitis. The pulse is sometimes accelerated and sometimes 
nearly natural. The emaciation in gastritis is rapid, since not only the milk 
is in great measure vomited, but the digestive function, so far as the stomach 
is concerned, is seriously impaired. The features become wrinkled and senile, 
the eyes hollow, the limbs attenuated, and the cranial bones uneven. Death 
occurs from exhaustion. 

Anatomical Characters. — Simple gastritis may afiect the entire mucous 
surface of the stomach or be limited to a certain part. The part which is most 
likely to escape is that toward the pyloric orifice. This portion of the organ 
is sometimes found in nearly or quite the normal state, while the cardiac half 
or two-thirds is inflamed. The vascularity of the diseased surface is not uni- 
form. In one place there is simple arborescence ; in another intense continu- 
ous redness ; and between these two extremes are different grades of vascu- 
larity. The mucous membrane is somewhat thickened, softened, and the 
secretion of mucus increased. Extravasation of blood is not infrequent 
under the mucous membrane, usually in points, and the mucus may be mixed 
with more or less blood. Small shreds or portions of coagulated milk are 
often found with the mucus attached to the gastric surface. I have observed, 
though rarely, small superficial ulcers at the point where the inflammation 
had been most intense. 

Dr. A. Jacobi says : " Indeed, the boundary-line between a simple dys- 
pepsia and a gastric catarrh is perhaps never made out clearly. The epithelium 
of the mucous membrane does not belong to it exclusively, but spreads in the 
contiguity of the tissues into the muciparous and the peptic glands. Thus 
the inflammatory condition of the surface becomes at once a parenchymatous 
affection, though it be possible that an uncomplicated catarrh and an uncom- 



774 INDIGESTION, CONGESTION OF THE STOMACH, ETC. 

plicated inflammation may have an occasional existence Unless a 

gastric catarrh or a dyspepsia .... be relieved at once the merely func- 
tional or superficial disorder becomes organic and deep-seated. These changes 
may refer either to the tissue or the secretion. Inflammatory thickening, 
erosions, ulcerations, or (Moncorvo) dilatation of the stomach will be observed 
in a great many instances. The secretions become abnormal ; the normal 

hydrochloric acid of the gastric juice is almost invariably diminished 

Lactic acid, however, is produced in much larger quantities than the first 
stage of digestion requires, and with it acetic, butyric, and the rest of the 
fatty acids." ^ 

Diagnosis. — In protracted cases, when entero-colitis is present, it is dif- 
ficult to make a positive diagnosis. Our opinion must then be little more 
than a plausible conjecture. In the acute attacks we can diagnosticate the 
gastritis with more certainty. If a young infant affected with sprue be 
seized with pain, and vomits often ; if emaciation be rapid and there be no 
diarrhoea, or diarrhoea not sufiicient to account for the prostration ; if the 
buccal mucous membrane, dotted with the points of thrush, present a dry 
appearance and the deep-red color of severe stomatitis, — there can be little 
doubt of the presence of gastritis. The diagnosis is rendered more certain 
by signs of tenderness when pressure is made upon the epigastric region. 

Prognosis. — Like other inflammations, gastritis is probably sometimes 
so mild that it does not materially increase the suffering or danger of the 
child. This mild form of the disease under favorable circumstances soon 
subsides. In other cases, by the continuance or increase of the cause, the 
inflammatory process becomes more severe and extensive, resulting even in 
disintegration of the mucous membrane. Those cases are especially severe 
and likely to end fatally which are protracted and accompanied by severe 
thrush, with a desiccated appearance of the buccal surface or with entero- 
colitis. Pain, vomiting, and rapid emaciation in such children indicate the 
speedy approach of death. Improvement in the stomatitis or entero-colitis 
is a favorable indication, but these inflammations may improve without cor- 
responding improvement in the gastritis. 

Treatment. — All foods or drinks, except those of a bland and unirritat- 
ing nature, should be forbidden. If practicable, the young infant should 
take no nutriment except the mother's milk or that of a wet-nurse. Since 
there is an excess of acid in inflammation of the mucous coat of the diges- 
tive tube, lime-water may be advantageously given in combination with 
breast-milk. Opium is required to relieve the pain and quiet the action 
of the stomach. The camphorated tincture of opium, in doses of four or 
five drops to a child a month old, or the syrup of poppy, tincture of opium, 
or licjuor opii compositus in proportionate doses, may be administered. If 
there be thirst a little gum-water should be given frequently. If there be 
much emaciation and the vital powers are failing, it will be necessary to 
resort to the use of stimulants. Stimulating enemata are preferable to 
stimulants given by the mouth. Much benefit may be anticipated from 
local measures. Irritation should be produced upon the epigastrium by 
mustard or other means, followed by fomentations. It is rarely, perhaps 
never, proper to use leeches if the patient be an infant. Death occurs 
from exhaustion, and it is therefore important that the vital powers should 
not be reduced. If the child be weaned, the diet at first should be restricted 
to arrowroot, rice-water, barley-water, or similar bland substances. In 
advanced stages of gastritis animal broths and jellies may be required. To 
relieve the thirst, carbonic-acid water, Vichy water, or plain water acidulated 
with a few drops of hydrochloric acid may be employed. If symptoms of 
1 Arch, of Pediatrics, Aug., 1889. 



FOLLICULAR GASTRITIS, ETC. 775 

indigestion continue, it may be best to employ bismuth and pepsin after the 
gastritis has abated. 

Follicular Gastritis ; Diphtheritic Gastritis. 

The pathological character of follicular gastritis is similar to that of fol- 
licular stomatitis. It is an inflammation aifecting the gastric follicles and 
ending in their ulceration. It is not a frequent disease ; it occurs in young 
infants. Billard observed fifteen cases. The symptoms in these patients 
were similar to those in simple gastritis of a severe form. The emaciation 
and prostration were rapid, and death occurred earl}^ We can only diag- 
nosticate the gastritis without determining its follicular character. How 
many recover it is impossible to ascertain, but the disease is likely to be 
fatal on account of the intensity of the inflammation, not only of the fol- 
licles, but of the intervening mucous membrane. The treatment is that of 
gastritis. 

Diphtheritic gastritis is infrequent. It occasionally occurs during epi- 
demics of diphtheria. Allusion is elsewhere made to a case treated in the 
Nursery and Child's Hospital of this city in December, 1859. The patient, 
eighteen months old, previously had had protracted entero-colitis, and died 
exhausted after a brief attack of diphtheria. There were lesions referable 
to the entero-colitis, and the body was much emaciated. The diphtheritic 
exudation was found covering the fauces, epiglottis, glottis to the rima glot- 
tidis, the entire oesophagus, and almost the entire stomach. The mucous 
surface underneath was injected ; that of the oesophagus and stomach espe- 
cially was very vascular, softened and thickened, and the submucous connec- 
tive tissue was infiltrated. 

The pseudo-membrane taken from the epiglottis and examined under the 
microscope presented an amorphous appearance ; no cells were noticed in it, 
and fibrillation was not distinct ; that from the stomach was found to consist 
almost entirely of cells, the plastic corpuscles of some writers, the pyoid of 
others. The digestive process, so far as the stomach was concerned, had 
evidently been almost if not entirely suspended, and hence in part the sudden 
prostration. Diphtheritic gastritis probably does not occur without general 
infection of the system with the diphtheritic virus. The proper treatment is 
the use of lime-water or one of the solvents of pseudo-membranes which do 
not irritate the mucous membrane, while the constitutional treatment proper 
for diphtheria is employed. 

Dilatation of Stomach. 

The stomach may undergo abnormal dilatation, according to Dr. A. Jacobi, 
from overfeeding with bulky, especially amylaceous, food ; from diminished 
contractility in its muscular coat consequent on debility ; from imperfect 
digestion and flatulence ; from catarrhal gastritis and peritoneal adhesions. 
In its treatment he recommends medicines (as bismuth) which diminish fer- 
mentation, the avoidance of fats and starches, and large quantities of fluid 
ingesta. Milk may be given in small quantities and often. Diarrhoea due to 
this state of the stomach, Jacobi says, may require astringents, as tannin. 
Raw beef, beef peptones, and peptonized milk are useful, as is also an 
abdominal binder. Faradic and galvanic currents have been used with some 
advantage, and the tincture of nux vomica or strychnia, gr. yi-g- to j\-^, 
three times daily, will increase the contractility of the muscular coat of the 
stomach.^ 

1 Arch, of Pediatrics, Aug., 18S9. 



776 INDIGESTIOK CONGESTION OF THE STOMACH, ETC 



Gastro-malacia. 

It is now many years since the attention of the profession was directed 
to disorganization of the coats of the stomach which is sometimes observed 
at post-mortem examinations. John Hunter first ascertained that the gastric 
juice begins to have a solvent effect on the tissues of the stomach soon after 
death. Though Hunter erred when he stated that the coats of the stomach 
are more or less digested in all or nearly all cases, it is certain that post- 
mortem digestion does take place in many cadavers, so that in a few hours 
after death the gastric mucous membrane is destroyed to a greater or less 
extent, and occasionally the stomach is perforated or is even severed from its 
connection with the oesophagus. I have seen several examples of this post- 
mortem digestion in infants. 

Most cases of supposed pathological softening of the stomach reported 
by the older observers seem to have been such as I have described — namely, 
cadaveric. It is now believed by pathologists that gastro-malacia always 
occurs as a cadaveric change, or, if it be pathological in exceptional instances, 
it in such cases takes place when the individual is nearly or quite moribund 
and the circulation of blood in it has come to the standstill. 

The so-called white softening of the stomach has been observed chiefly 
in the bodies of those who during life were anaemic and ill-nourished. The 
mucous membrane in such cases has lost its firmness, and is easily separated 
from the subjacent tissue. This softening has no connection with any inflam- 
matory process. It is the result of the low vitality of the patient. I believe 
that in a large proportion of infants whose systems have been reduced and 
blood impoverished for a considerable time the gastro-intestinal mucous mem- 
brane will be found after death less firm and resisting than in those who have 
been habitually robust. 

A vague opinion exists in the minds of most physicians as to the nature, 
and even appearance, of the so-called gelatinous softening of the stomach, 
and the following observations will be cited in order to give a clearer idea 
of it : 

Billard has recorded two cases with his usual minuteness, and adds : 
" What inference shall be drawn from the preceding facts and considera- 
tions ? None other than that the gelatinous softening of the stomach con- 
sists in a disorganization of the mucous membrane of this viscus, caused by 
an acute or chronic phlegmasia ; that this disorganization is characterized 
by an accumulation of serum in the walls of this organ ; the intumescence 
and gelatinous consistence of the mucous membrane in a part usually cir- 
cumscribed are situated more frequently in the greater curvature, and about 
which the membrane exhibits more or less evident traces of an acute or 

chronic phlegmasia The softening now under consideration must not 

be confounded with another kind of softening " (white), " which does not 
usually succeed an acute phlegmasia." 

West, in speaking of gelatinous softening, says : " Softening of the 
stomach varies in degree from a slight diminution in the consistence of the 
mucous membrane to a state of complete diffluence of all the tissues of the 

organ When the change is not far advanced the exterior of the 

stomach presents a perfectly natural appearance, but on laying it open a 
colorless or slightly brownish tenacious mucus, like the mucilage of quince- 
seed, is found closely adhering to its interior over a more or less considerable 
space at the great end of this organ." 

Cruveilhier says : " This softening often proceeds from the interior toward 
the exterior. There is at the beginning simple separation of the fibres by a 
gelatinous mucus, and in consequence the parietes are thickened and semi- 



GASTE 0-MALA CIA. 777 

transparent If the transformation be complete, the disorganized por- 
tions are removed layer after layer, those which remain becoming gradually 
thinner. The peritoneum alone resists for some time, but at length it is 
attacked, worn, and gives way, and perforation of the stomach results. The 
parts thus transformed are colorless, transparent, apparently inorganic, 
completely deprived of vessels, and exhaling an odor resembling that of 
milk." 

Bouchut remarks : '• Softening of the mucous membrane of the stomach 
in children at the breast is not a special disease which it is necessary to 
describe by itself. This alteration is always connected with other diseases, 
and especially with disease of the large intestine, the knowledge of which 
fact has been too long neglected. It is the consequence of the acidity of the 
liquids contained in the digestive tube of young children — liquids which are 
very acid in the disease we have above referred to." 

Rokitansky says of this form of softening : '• If we consider, in addition 
to the above remarks, the uniform localization of the disease, that in none of 
its stages it presents, either at the point of the softening or in its vicinity, 
hyperasmic injection or reddening, and that we are still less able to demon- 
strate upon the inner surface of the stomach or in the tissue of its coats the 
products of inflammation, we are constrained to infer the non-inflammatory 
nature of the aifection. ' 

Without extending these extracts it is seen that eminent authorities not 
only disagree in reference to the cause of gelatinous softening of the stomach, 
but that they also diS"er in their description of its appearances. This diver- 
sity of opinion is most likely attributable to the fact that the two kinds of 
softening have been confounded. Rokitansky and Bouchut probably refer to 
cases of white softening which occur in atonic states of the tissues in feeble 
infants, and therefore have concluded that softening of the stomach is not 
inflammatory. I believe, from my observations, that the opinion of Billard 
is correct, and that true gelatinous softening is sometimes found in stomachs 
that have been inflamed, but it may be in such cases cadaveric. 

The following case, which was watched by myself with great interest 
from beginning to end, was an example of softening following gastritis : 

Case. — G. S. , male, robust, was born July 10, 1865. The mother not 

being able to suckle the infant, and the danger of artificial feeding in the warm 
months being well understood, a wet-nurse was procured. About the 14th of 
July, this wet-nurse having insufficient milk, another was procured temporarily, 
who suckled the infant till July 20th, when a third wet-nurse was engaged, 
whose child, healthy and thriving, was six weeks old. Previously to this time 
the infant appeared well. It had uniformly nursed vigorously and seemed 
satisfied. 

On the 22d of July thrush, apparently mild, was observed in the mouth, and 
a powder, supposed to be borax, and labelled such, was obtained at a drug-store 
to be used as a wash for the mouth. This powder was afterward ascertained to 
be alum. Five grains were dissolved in as many teaspoonfuls of water, and the 
mouth of the child was swabbed occasionally with it. A piece of linen, folded 
so as to resemble the tip of a nursing-bottle, was occasionally dipped into the 
solution, and the infant was allowed to suck it. The use of the alum was com- 
menced about 6 P. M. In the first part of the evening the infant slept consider- 
ably, and of course did not nurse often, but about 8 p. m. it began to be very 
fretful, and it then nursed more frequently. It vomited once between 8 and 10 
o'clock p. M. In order to quiet the infant the tip soaked in the solution was often 
applied to the mouth, but there was scarcely any intermission in its crying. 
Through the night it vomited again once or twice, and about the middle of the 
night had one free liquid stool, which was passed with much tenesmus. The 
countenance of the infant was indicative of suffering, and its thighs were repeat- 
edly flexed over the abdomen, as if that were the seat of its distress. Paregoric 



778 INDIGESTION, CONGESTION OF THE STOMACH, ETC. 

in two-drop doses was several times given through the night, and flannel soaked 
witli hot whiskey was applied to the abdomen. 

July 23d : In ignorance of the cause of the child's sickness another wet-nurse 
was obtained early in the morning, and one-sixth of a drop of liq. opii compos, 
was given every hour, with the effect of inducing a little sleep. The tongue was 
very red, desiccated, and studded with more numerous points of thrush than on 
the previous day. It now refused to nurse, apparently from soreness of the 
tongue. At each attempt of the nurse to induce it to take the nipple, it rubbed 
the mouth across the breast, crying either from pain or disappointment. The 
alum was not used in the latter part of the night of the 22d, but late in the 
morning of the 23d it Vv^as resumed, the mistake of the druggist not being discov- 
ered till mid-day, when it was estimated that about five grains had been used. 
Occasionally a little of the solution was placed in the mouth with a spoon, so as 
to be swallowed, in the belief that the thrush affected the oesophagus. The infant 
continued to suffer much during the day, sleeping at times a few minutes. Its 
strength was evidently failing ; respiration regular ; pulse about 140 ; its alvine 
discharges yellow, of natural consistence and frequency. 

Evening 23d: Surface hot; it is very restless; pulse 150 to 160; tongue dry, 
intensely red, and dotted with points of thrush. Is treated with opiates, a little 
lime-water, and fomentations. 

24th : In the first part of the day nursed pretty well ; in the latter part could 
be induced to draw the breast only once or twice. The symptoms to-day were 
the same as yesterday, with the exception of greater emaciation and prostration ; 
cranial bones uneven and features pinched. 

25th : Pulse 140 to 148 ; strength rapidly failing, but it cries at times loudly. 
The milk of the nurse, placed in the mouth with a spoon, is often held a consid- 
erable time before it is swallowed, and deglutition seems difficult. Respiration 
in the first part of the day and previously natural ; in the latter part of the day 
accelerated ; dejections natural ; no vomiting ; appearance of tongue more natural 
than yesterday. 

26th: Died to-day in a state of collapse at 12.30 P. M. The hands were cold 
several hours before death, and the milk given it was regurgitated. 

Autopsy, Twenty-two Hours after Death. — Much emaciation; no rigor mortis; 
cranial bones uneven ; the upper part of the pharynx injected to the extent of 
about half an inch ; from this point to the stomach membrane healthy ; mucous 
membrane covering the cardiac two-thirds of the stomach disintegrated, almost 
diffluent, and in places detached from the subjacent tissues ; mucous coat of the 
pyloric third of the organ nearly healthy ; along the edge of the softened portion 
the mucous membrane was vascular to the extent of a few lines ; the muscular 
and serous coats of the stomach underneath the softened portion were easily 
torn ; the mucous membrane of the small intestine presented in places that 
degree of vascularity known as arborescence ; there was no destruction or soften- 
ing of its mucous membrane ; the colon was healthy ; the stomach was nearly 
empty ; the contents of the small and large intestines were natural in color and 
consistence ; the other viscera were healthy ; in the left pleural cavity was about 
one ounce of transparent serum and a less quantity in the right cavity. 

The weather at the time was warm, but the infant was placed on ice, and 
a pan containing ice was kept upon the abdomen. It evidently died of 
gastritis, the accompanying inflammation being subordinate, and in fact insig- 
nificant. At first it was a question with me whether the alum might not 
have caused the gastritis, so that the case should be properly placed in the 
category of deaths from swallowing corrosive substances. In order to deter- 
mine this point, I administered alum daily to two kittens, commencing when 
they were seven days old. The quantity given to each was ten grains daily 
in two doses for three consecutive days, and on the two following days five 
grains. The only uniform result noticed was an increased flow of saliva, 
which washed some of the alum from their mouths, and occasionally slight 
vomiting. There was not even any apparent inflammation of the buccal 
membrane from the alum. 

Post-mortem appearances, as in the above case, and similar ones recorded 



G ASTRO-INTESTINAL BACTERIA. 779 

by Valleix and others, in which gelatinous softening coexisted with evident 
lesions of gastritis, render it highly probable, if indeed they do not demon- 
strate, that the softening is one of the sequels of the inflammation at the 
point where it occurs ; but whether it begins in the moribund state or is 
entirely cadaveric is uncertain. 

In Valleix's twenty-four cases of what he terms fatal muguet, softening of 
the mucous membrane of the stomach was one of the most common lesions, 
and at the same time, which is the point of interest, there were signs which 
showed conclusively the presence of gastric inflammation. The common 
coexistence of the lesions of gastric inflammation, such as redness and 
thickening, with gelatinous softening of the stomach, is a fact that arrests 
attention, and strengthens the belief that gastro-malacia is one of the sequelae 
of gastritis. 

I am not prepared to accept nor reject the theory of Billard that the 
immediate cause of the softening is the afflux of serum, nor that of 
Bouchut that it is an excess of acid. 

It has been said that M. Baron was able to diagnosticate gelatinous soft- 
ening. The symptoms are those of the severe forms of gastritis. The vom- 
iting, great pain, restlessness, sudden and progressive emaciation, and finally 
collapse preceding the fatal result, without suflicient diarrhoea to cause the 
rapid sinking, are the symptoms on which the diagnosis was based. These 
symptoms indicated a gastritis, but physicians of the present time would 
hardly consider them sufficient to justify the diagnosis of gastro-malacia. 



CHAPTER YI. 

GASTEO-INTESTINAL BACTERIA. 

Recent investigations have demonstrated that these organisms sustain 
an important causal relation to the indigestion, malassimilation, and diar- 
rhoeal diseases of infancy. They are minute unicellular bodies, and are 
classified as follows : first, the micrococci, or globular bacteria ; secondly, the 
bacilli, or rod-shaped bacteria ; and thirdly, the spirilla or spiral bacteria. 

The pathogenic character of these bodies has been to a considerable 
extent elucidated by the microscopic examinations and experiments of seve- 
ral European scientists, prominent among whom is Escherich, and by the 
investigations of Booker and Vaughan in America. 

Bacteria are not present in the stomach and intestines in the foetus, nor 
in the meconium at birth. They are conveyed to the digestive tract of the 
newly-born through the air and saliva and the liquid ingesta, and it is 
believed that they sometimes obtain entrance through the anus, for they 
have been found in the meconium three to seven hours after birth (Escher- 
ich). When the meconium is expelled the bacteria which it contains disap- 
pear, and other species subsequently take their place in the milk-feces. 
The feces of healthy nurslings contain a larger number of bacteria, of which 
the bacterium lactis aerogenes and bacterium coli commune are uniformly 
present. According to Booker, in the healthy suckling the stomach contains 
few bacteria, chiefly bacilli ; the duodenum also contains but few ; but they 
increase in number on tracing the intestine downward. On reaching the 
lower end of the upper third of the small intestine, we find a considerable 
number of bacteria, including diplococci, bacteria lactis aerogenes, and colon 



780 G ASTRO-INTESTINAL BACTERIA. 

bacteria. The bacteria lactis aerogenes undergo no farther increase in the 
lower part of the small intestines and in the colon, but the colon bacteria 
(bacterium coli commune) undergo a great increase in number in the lower 
part of the ileum and in the colon. They exist in large numbers in the entire 
length of the colon, and of larger size than in the small intestine. The bac- 
terium lactis aerogenes occurs in the form of " short, thick rods, with rounded 
ends." Injected into the blood of guinea-pigs and rabbits, it causes death, 
preceded by the phenomena of intestinal catarrh. The bacterium coli com- 
mune is believed to be always present in feces, whatever the diet. It is also 
rod-shaped and it varies in size and length, the largest and longest specimens 
attaining the length of five micro-millimetres. According to Booker, both 
these microbes promote fermentation in the intestines. Many other forms 
of bacteria have been discovered in the milk-feces of infants, in addition to 
the two which we have described. Escherich discovered twelve varieties, 
micrococci and bacilli. 

To the physician the gastro-intestinal bacteria are mainly interesting on 
account of the supposed causal relation which they sustain to certain abnor- 
mal conditions of the digestive tract, especially to the diarrhoeal affections. 
It is important in investigating this subject to ascertain what bacteria are 
present in normal feces, and whether they exert pathogenic action under 
certain circumstances. This has been, in a measure, ascertained, as we have 
seen, but another interesting and important inquiry relates to new forms 
of bacteria that appear in the feces in diseased conditions of the stomach 
and intestines, and the causal relation which they bear to these conditions. 
New forms of bacteria may appear in the feces in gastro-intestinal disease 
without sustaining a causal relation to it or influencing it. Again, although 
not causing the disease, they may influence its course and duration, or they 
may cause gastro-intestinal disease by lodging in the food, especially in milk, 
and producing by their agency poisonous chemical substances in it before it 
is employed in the nursery. The well-known poisoning by the tyrotoxicon 
in the hotels at Long Branch, this poison being produced in milk proba- 
bly by microbic action six or eight hours after the milking, was an instance 
of this kind. Again, a species of bacteria not occurring in the stools in 
health, but appearing in disease, as in indigestion, inanition, or diarrhoea, 
may be the chief factor in causing this morbid state. 

According to Booker, none of the gastro-intestinal secretions has an 
injurious effect on bacteria, except the gastric juice, but certain bacteria are 
antagonistic to others, so that their presence prevents the full development 
of the latter. Bacteria, which in the normal state of the gastro-intestinal 
tract do not find a soil suitable for their development in the stomach or 
intestines, obtain the conditions favorable for their growth and propagation 
in diseased states, as when indigestion or catarrh is present. 

The pathogenic action of bacteria in the digestive tract can be most suc- 
cessfully investigated by experimenting with them when they have been 
isolated from other substances by repeated cultivations. Hayem and Le- 
sage have isolated a bacillus which they have discovered in green stools of 
infants, and which they believe produces by its disturbing action the green 
color and abnormal state of the stools. The green color in the- feces of 
infantile diarrhoea they believe to be sometimes due to an excess of the bile- 
pigment, but in other instances is produced by the action of a bacillus, which 
occurs especially in the upper two-thirds of the small intestine, where it 
attains the length of two to three micro-millimetres. Injected into the 
blood of sucking animals, this bacillus appeared in the duodenum ten or 
twelve hours subsequently, and, increasing in number, caused green colora- 
tion of the intestinal contents. The same result was produced when this 



SIMPLE JDIAREHCEA. 781 

microbe was administered in the ingesta. In its dry state it floats in the air, 
so that when an infant having green stools produced by its action enters a 
ward, others are liable to be attacked with the green diarrhoea if its soiled 
diapers are allowed to dry in the room. 

Baginsky has investigated the stools in the acid diarrhoea of infants, and 
has isolated two forms of bacteria which liquefy gelatin. One of these pro- 
duces green coloring matter, and is probably the same as that described above ; 
the other was constantly present in the acid diarrhoeal feces, was poisonous 
to animals, and it is probably impotent in the pathogenic role. Baginsky 
believes from his observations that the bacterium lactis aerogenes present in 
the normal stools of the suckling is under favorable circumstances antagonis- 
tic to the development of pathogenic organisms. 

Dr. Booker has isolated forty bacteria from the stools of 30 infants, all 
seriously sick with diarrhoeal diseases, 11 having cholera infantum, 14 catar- 
rhal enteritis, and 5 dysentery. The largest number of these organisms 
occurred in cases of cholera infantum, and the next largest number in cases 
of catarrhal entero-colitis. According to Booker, the bacteria of the normal 
milk-feces still appear in the diarrhoeal stools. The bacterium coli commune 
was found by him in all the diarrhoeal cases, but its number appeared to 
diminish according to the severity of the attack. On the other hand, the bac- 
terium lactis aerogenes occurred in larger number in the diarrhoeal stools than 
in healthy milk-feces. Booker discovered bacteria of the proteus group in 
7 of the 1 1 cases of cholera infantum ; which is a matter of significance, inas- 
much as Escherich did not find any bacterium of this group in normal milk- 
feces. 

In a very interesting and instructive paper read before the American 
Pediatric Society in June, 1890, Dr. Victor C. Vaughan detailed his experi- 
ments, which showed that '• three micro-organisms, differing sufficiently to be 
recognized as of diiferent species, produce poisons, all of which induce vom- 
iting and purging, and when used in sufficient quantity, death " in cats and 
dogs experimented on. Dr. Vaughan concludes his paper with the following 
aphorisms: •' 1st. There are many germs, any one of which, when introduced 
into the intestine of the infant under certain favorable circumstances, may 
produce diarrhoea. 2. Many of these germs are probably truly saprophytic. 
3. The only digestive secretion which is known to have any decided germici- 
dal efi'ect is the gastric juice. Therefore, if this secretion be impaired, there 
is at least the possibility that the living germ will pass on to the intestine, 
will there multiply, and will, if it be capable of so doing, elaborate a chem- 
ical poison, which may be absorbed. 4. Any germ which is capable of grow- 
ing and producing an absorbable poison in the intestine is a pathogenic germ. 
5. The proper classification of germs in regard to their relation to disease 
cannot be made from their morphology alone, but must depend largely upon 
the products of their growth.'' 



CHAPTER YII. 

SIMPLE DIARRHCEA. 

DiARRHCEA is frequent during the whole period of infancy. French 
writers describe several varieties, according to the character of the evac- 
uations, as acescent, mucous, and serous. M. Eostan even describes four- 



782 SIMPLE DIARRHOEA. 

teen distinct kinds. But the tendency of medical science in modern times 
is to simplify the nomenclature of diseases — to describe under a single name 
those affections which are essentially the same, though differing somewhat 
in their features. Now, all the forms of diarrhoea in the infant may be 
so grouped as to reduce the number to not more than three or four. In 
this way repetition and prolixity are avoided, as well as an unnecessary 
refinement. 

The most common form of diarrhoea is that enunciated in our heading. 
But often a diarrhoea which is non-inflammatory at first becomes a catarrh. 
Thus the simple diarrhoea of infancy may become an entero-colitis from the 
continued use of improper diet. 

Causes. — These are various. Conditions or agencies which have no 
appreciable effect in the adult often increase the number of evacuations 
in young children. Food which imperfectly digests, and some of which 
perhaps ferments, stimulates the intestinal follicles to excessive secretion, 
and increases the peristaltic movements by its irritating action, thus causing 
diarrhoea. Too frequent and abundant feeding is another cause, especially in 
young infants, some of whom may vomit the suplus food and remain well, 
but others do not. Food which cannot be assimilated becomes an irritant in 
consequence of fermentative change, and produces frequent and unhealthy 
evacuations. In the light of our present knowledge we assign to the agency 
of intestinal bacteria an important causal relation to those forms of diar- 
rhoea which are attended by fermenting, imperfectly-digested, and unhealthy 
stools. 

The mother's milk or the milk of the wet-nurse may disagree, either 
from some temporary derangement of her system or continued ill-health, or 
from causes which are not understood. Diarrhoea in the nursling is the 
result. 

Fright or strong mental impressions will also in some children increase, 
the number of evacuations. This cause being transient, the diarrhoea soon 
subsides. 

Another cause is exposure to cold. Children who are insufficiently 
clothed in the winter season, who are taken from a heated room into a 
cool one without sufficient protection, or who lie uncovered at night, are 
very subject to diarrhoeal attacks from the impression of cold on the 
system. 

The cause of simple diarrhoea may exist in the child itself. In some 
children the evolution of the teeth is attended by a relaxed state of the 
bowels, which ceases when the gum is pierced. Worms in the intestines 
may also operate as a cause. Diarrhoea is occasionally salutary within cer- 
tain limits, and of course it is not strictly correct to call it a disease when it 
is a means of relief. If occurring from excessive or irritating ingesta, it is 
obviously conservative. 

Symptoms. — Diarrhoea may come on suddenly ; at other times there are 
precursory symptoms continuing for some days. Whether or not there be 
antecedent symptoms depends chiefly on the cause. If this be exposure to 
cold or the use of improper aliment, it commonly occurs immediately. 

Among the prodromic symptoms sometimes present are restlessness, dis- 
turbed sleep, transient abdominal pains, nausea or vomiting, and other symp- 
toms of indigestion. The stools in simple diarrhoea differ much in color and 
consistence in diff"erent cases, and perhaps at diff'erent periods in the same 
case. In infants they are often green. This color, which is a source of 
anxiety to the inexperienced, and especially to the parents, is often produced 
by trivial causes. Slight indigestion will produce it, and so will excess of 
food, even when bland and unirritating. In our remarks on the gastro-intes- 



AXATOMICAL CHARACTERS. 783 

tinal bacteria we have stated that a microbe has the power to produce the 
green color. The stools in infantile diarrhoea often contain particles of coag- 
ulated casein, but in children advanced beyond the period of first dentition 
they do not differ materially in appearance from the evacuations of the adult. 
They are usually passed easily, but if they be acid or in any way irritating 
there may be more or less tenesmus, especially in infants. Sometimes before 
the evacuations there is a sensation of fulness in the abdomen. In that form 
of diarrhoea which has been designated acescent not only are the stools acid, 
but matters vomited have an acid odor and give an acid reaction. 

During the quiet hours of sleep, when no foods and drinks are taken, the 
diarrhoea diminishes. If the complaint be slight, there is little thirst ; but 
if the stools be frequent and thin, especially if they approach the watery 
character, the patient is thirsty. The appetite varies, the tongue is moist 
and covered with a light fur, and there is often more or less meteorism, 
but no abdominal tenderness. 

The features in this disease are pallid. In a few days, if the evacuations 
continue, there is evident loss of weight and flesh. The rotundity of the 
limbs is gradually lost and the tissues become soft and flabby. But in most 
cases when the malady has reached this stage its original character is lost, 
and it has become inflammatory. 

Certain epiphenomena, as Barrier terms them, occur at times in non- 
inflammatory as well as in inflammatory diarrhoea ; as, for example, a sym- 
pathetic cough or, which is more serious, cerebral complications. Convul- 
sions or stupor, indicating the supervention of spurious hydrocephalus, may 
occur in either form of diarrhoea. This disease is described elsewhere. More 
or less fever may occur in simple diarrhoea, but it is not constant and the 
pulse may or may not be accelerated. 

Anatomical Characters. — It is obvious from the nature of simple 
diarrhoea that it is attended by little or no structural changes perceptible to 
the anatomist. In cases supposed to be simple or non-inflammatory, which 
have ended fatally either from the diarrhoea or an intercurrent disease, the most 
marked leisons observed have been more or less tumefaction of the intestinal 
glands, with perhaps diminished firmness and resistance of the mucous mem- 
brane. Cases like the following, which have usually been regarded as non- 
inflammatory, are not infrequent, but it seems to me probable that in at least 
a certain proportion of such cases the intestinal follicular apparatus has passed 
beyond the physiological state of an exaggerated functional activity, and that 
the disease should be designated a catarrh or inflammation. Inasmuch as 
non-inflammatory diarrhoea, if protracted, is very liable to become inflamma- 
tory, it is often difficult to determine whether the malady has undergone this 
change, even with the aid of post-mortem inspection. 

On the 7th of July, 1865, a foundling one month old died at the Infant 
Asylum. It was much emaciated, with eyes sunken and features pinched, 
at the time of its death. It was wet-nursed to the close of its life, but the 
nurse's milk was insuflicient. It did not vomit, did not have any marked 
acceleration of pulse (128 per minute), and its evacuations were about four 
daily, and thin. The stomach and intestines were pale throughout. The 
solitary glands, particularly those in the colon, and the patches of Peyer, 
were tumefied so as to be visible and somewhat raised above the surround- 
ing surface. But no lesions being observed which are characteristic of 
inflammation, the disease was regarded as non-inflammatory. 

Niemeyer, with others, describes even the mildest forms of diarrhoea under 
the term catarrhal inflammation, and he appears to consider the transient 
efi"ects of a purgative as an incipient catarrh. But it seems to me prefer- 
able, in the present state of pathological knowledge, to regard all those diar- 



784 SIMPLE DIARRHCEA. 

rhoeas which immediately abate with the removal of the cause, and which are 
attended by no marked anatomical change, as non-inflammatory or simple. 
They are characterized by increased secretion of the intestinal follicles and 
increased peristalsis. 

Prognosis. — In a large proportion of cases simple diarrhoea is not dan- 
gerous. With the adoption of suitable measures to remove the cause and 
the use of medicines to control the discharges the patient recovers. The 
remark already made may be repeated here, that occasionally diarrhoea is 
salutary within certain limits, as when there is a foreign substance in the 
intestines either irritating mechanically or by its chemical properties, and 
which the diarrhoea serves to remove. 

The danger arises from complications, as spurious hydrocephalus, or from 
the emaciation and exhaustion, or from its eventuating in inflammation. 

If the rotundity of the figure and firmness of the tissues be preserved, 
showing that alimentation is still sufficient, and no complication arise, the diar- 
rhoea is not as a rule dangerous. In infants that over-nurse and do not vomit 
the surplus milk, the evacuations are sometimes green and frequent, and yet 
fulness of figure is preserved and the development of the body proceeds as 
usual. On the other hand, diarrhoea attended by emaciation or softness or 
flabbiness of the flesh involves danger and requires immediate treatment. 

Treatment. — It is necessary, in order to treat diarrhoea in infancy and 
childhood successfully, to ascertain the cause, and, as far as possible, to 
remove it. It is not till the cause ceases to operate that we can expect a 
satisfactory result from medication. The disease may be temporarily relieved 
by medicine, but it usually returns at once when treatment is omitted, unless 
the patient be removed from the influence of the agencies which produce it. 
These remarks are especially applicable to the diarrhoea of infants. With 
them very generally, when aff"ected with this complaint, there is some fault 
as regards the quantity or quality of food. Attention to this matter will 
show the need of a change of wet-nurse, or, if the infant be spoon-fed, a 
change in the character of its food or in the mode of preparation, or even in 
the quantity given. Sometimes by change in the diet and the adoption of 
hygienic measures the complaint ceases, so as to require no medication. 
Sometimes the temporary abstinence from milk-food, and the employment 
of barley gruel in its place or the use of barley gruel and peptonized milk, 
suffice to cure the diarrhoea. If medicines be needed and the symptoms are 
not urgent, it is occasionally advantageous to commence treatment by the use 
of one of the milder purgatives in a small dose. In the ivfanf, in whom the 
dejections are so generally acid, an alkaline laxative or a laxative conjoined 
with an alkali often has a good eflfect as preliminary treatment. Half a tea- 
spoonful to one teaspoonful of castor oil or a proportionate dose of calcined 
magnesia removes any acid or irritating substance from the intestines, and is 
followed by a diminution in the number of stools. The improvement, how- 
ever, without subsequent treatment is usually only for a day or two. In this 
city a purgative dose of castor oil is often given as a domestic remedy in 
infantile diarrhoea, the beneficial efl'ect from it having popularized its use for 
this purpose. Trousseau usually gave Rochelle salts, but this medicine is 
too severe and dangerous for the treatment of infantile diarrhoea, especially 
in v/arm months. 

If there have been previous constipation and the diarrhoea have Just com- 
menced, a purgative is obviously indicated. West says : " Provided there 
be neither much pain nor much tenesmus, and the evacuations, though 
watery, are fecal and contain little mucus and no blood, very small doses of 
the sulphate of magnesia and tincture of rhubarb have seemed to me more 
useful than any other remedy : • 



INTESTINAL CATARRH OF INFANCY. 785 

R. Magnesise sulphatis, 5j ; 

Tinct. rhei, 3j ; 

Syr. zingiberis, 3J ; 

Aqu?e carui, ^ix. Misce. 
3j' ter die for children one year old, 

I seldom fail to observe from it a speedy diminution in the frequency of 
the action of the bowels, and a return of the natural character of the 
evacuations." 

Since many cases of simple diarrhoea are due to the use of food which 
does not readily digest, but undergoes in part fermentation, the food should 
be carefully selected and prepared according to the directions given in the 
chapters relating to artificial feeding. In cases of fermentation, due often 
to microbic agency, the digestion is very imperfect, and the diarrhoea which 
results is often best treated, so far as medicines are concerned, by the use of 
pepsin and bismuth subnitrate. as ten or fifteen grains of pepsinum sac- 
charate and bismuth subnitrate, given at each feeding, with perhaps an equal 
quantity of bismuth in mistura creta midway between the feedings. 

In the simple diarrhoea of infants the compound powder of chalk and 
opium is sometimes an excellent medicine, containing as it does an astringent 
with the opiate and alkali. It may be given in doses of three grains to a 
child one year old every three hours midway between the feedings. The 
following is a convenient formula for administering substantially the same 
medicines in the liquid form : 

R. Tinct. opii deodorat., gtt. xvj ; 

Bismuth, subnitrat,, ^ij ; 

Syr. simplic, ,^ss; 

Mistur. cretae, ^iss. Misce. 

Shake well, and give one teaspoonful every three hours between the feedings. 

I often employ this prescription or one similar to it at my first visit. If 
the patient be not relieved by the opiate, alkali, and bismuth, and by proper 
regimen, in all probability inflammation of the intestinal mucous membrane 
is present. In patients over the age of two or three years simple diarrhoea 
approaches in character that of the adult, and the treatment appropriate for 
the adult is proper in these cases, allowance being made for the difference in 
age. In infants, in whom this disease, if protracted, very soon becomes an 
undoubted entero-colitis, attended if it be protracted by emaciation and weak 
heart, alcoholic stimulants are often required at an early period on account 
of the prostration and feeble power of endurance. 



CHAPTER VIII. 

INTESTINAL CATAKRH OF INFANCY (ENTEEO-COLITIS). 

It is customary with writers to treat of inflammation of the small and 
large intestines in infancy as a single disease, for the following reasons: 
First, the symptoms of colitis at this period of life do not ordinarily diff"er, 
in any marked degree, from those of enteritis. The tormina, tenesmus, and 
abdominal tenderness which characterize colitis in childhood and adult life 
are ordinarily lacking or are not appreciable by the observer, and the muco- 
sanguineous evacuations are oftener absent than present. On account of this 

50 



786 INTESTINAL CATARRH OF INFANCY. 

absence of symptoms Bouchut says: "Dysentery is a very rare disease 
among young children. Its existence might even be denied if it had not 
been observed at the period of some severe epidemics of dysentery." If 
Bouchut refers by the term dysentery to the ordinary phenomena of that 
disease, his remark is correct ; but as regards the lesions it is erroneous, for 
colitis is a common infantile malady. Billard, after analyzing eighty cases 
of intestinal inflammation in infants, says : " From this calculation it is 
evidently very difficult to make a correct diagnosis of inflammation of the 
intestinal tube in sucking infants, yet it would seem as if the proper signs 
of enteritis or ileitis were the rapid tympanitis of the abdomen, the diar- 
rhoea, accompanied with vomiting ; while in colitis, diarrhoea alone, without 
tympanitis, is the most frequent." And again : " In consequence of the 
impossibility we have found to exist of tracing with exactitude the series of 
symptoms proper to inflammation of the diff'erent portions of the digestive 
tube, we shall content ourselves with presenting an analytical sketch of the 
causes, symptoms, and ordinary course of inflammation of the mucous mem- 
brane of the intestines in general." 

The frequent absence of any pathognomonic symptom or sign by which 
to determine the exact seat of intestinal inflammation in the infant is admitted 
by recent observers as well as Billard. 

The second reason why intestinal inflammation in the infant is described 
as a single disease is, that enteritis and colitis in the majority of cases coexist. 
This will be seen when we come to speak of the anatomical characters. 

In rural districts infantile diarrhoea is not so prevalent and fatal as in 
cities. In the farming sections it does not materially increase the death-rate, 
and it is therefore not so important a malady as in cities. In cities it largely 
increases the aggregate of deaths. Especially fatal is that form of it which 
is known as the summer epidemic, as is seen by the mortuary records of 
any large city. Thus, in New York City during 1882 the deaths from diar- 
rhoea reported to the Health Board, tabulated in months, were as follows : 

Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. 
Under five years . .34 32 50 50 72 231 1533 817 362 195 68 35 
Over five years ... 14 15 14 20 15 19 131 149 84 55 31 24 

It is seen that in 1882 in New York City the deaths from diarrhoea under 
the age of five years were greatly in excess of the number during the whole 
period of life subsequently to that age. 

The following statistics show how great a destruction of life this malady 
causes even under the surveillance of an energetic Health Board ; and before 
this Board was established it was much greater, as I had abundant opportuni- 
ties to observe. The last annual report of the New York Board of Health 
was made in 1875, since which time weekly bulletins have been issued. The 
deaths from diarrhoea at all ages in the last three years in which annual 
reports were issued were as follows : 

1873. 1874. 1875. 

January . 94 43 46 

Februarv 84 34 52. 

March : 93 40 58 

April 114 47 45 

May 95 61 89 

June 220 144 157 

July 1514 1205 1387 

August 967 1007 1012 

September 424 587 608 

October. 213 ■ 255 185 

November 87 105 57 

December 53 56 50 



ETIOLOGY. 787 

In its annual report for 1870 the Board states: "The mortality from the 
diarrlioeal affections amounted to 2789, or 33 per cent, of the total deaths ; 
and of these deaths, 95 per cent, occurred in children less than live years 
old, 92 per cent, in children less than two years old, and 67 per cent, in those 
less than a year old." Every year the reports of the Health Board furnish 
similar statistics, but enough have been given to show how great a sacrifice 
• of life infantile diarrhoea produces annually in this city. 

What we observe in Xew York in reference to this disease is true also, to 
a greater or less extent, in other cities of this country and Europe, so far as 
we have reports. Not in every city is there the same proportionate mortality 
from this cause as in New York, but the frequency of infantile diarrhcDea and 
the mortality which attends it render it an important disease in, I believe, 
most cities of both continents. In country towns, whether in villages or 
farm-houses, this disease is comparatively unimportant, inasmuch as few cases 
occur in them, and the few that do occur are of mild type, and consequently 
much less fatal than in cities. 

The comparative immunity of rural districts has an important relation, as 
we will see, to the hygienic management of these cases. 

Etiology. — The intestinal catarrh of infants is occasionally produced by 
taking cold. Infants insufficiently protected by clothing and exposed to 
sudden changes of temperature or to currents of air in the apartments 
where they reside, or heedlessly exposed outdoor by careless nurses, some- 
times become affected with diarrhoea, even of a fatal character. They con- 
tract an intestinal inflammation from taking cold, just as other infants may 
contract coryza or bronchitis from the same cause. 

But the most common causes of infantile diarrhoea are, first, the u.se of 
food which is unsuitable for infantile digestion, and which therefore acts as 
an irritant : and, secondly, residence in a foul atmosphere, to which we will 
soon call attention, and which largely increases the percentage of deaths in 
our cities during the hot months. Diarrhoea due to taking cold occurs in all 
localities and climates, but it is obviously most common in times of change- 
able weather. That due to the use of unsuitable food and foul air occurs for 
the most part in cities, and much more frequently in the summer season than 
in the cool months, as the above statistics show. Infantile intestinal catarrh, 
however produced, presents nearly the same anatomical characters, so that, 
whatever its etiology, it is proper to describe it as one disease ; but that form 
of it which requires most elucidation, and the causes of which we will con- 
sider in the following pages, is that produced by impure air and improper 
diet. 

The prevalence and severity of infantile diarrhoea in cities correspond 
closely with the degree of atmospheric heat, as may be inferred from the 
foregoing statistics. In New York this disease begins in the month of May 
— earlier in some years than in others — in a few scattered cases, commonly 
of a mild type. Cases become more and more numerous and severe as the 
weather grows warmer, until July and August, when the diarrhoea attains its 
maximum prevalence and severity. In these two months it is by far the most 
frequent and fatal of all the diseases in the cities. In the middle of Sep- 
tember new patients begin to be less common, and in the latter part of this 
month and subsequently new cases do not occur, unless under unusual cir- 
cumstances which favor the development of this malady. In New York a con- 
siderable number of deaths of infants occur from diarrhoea in October. October 
is not a hot month in our latitude — its average temperature is lower than that 
of May — and yet the mortality from this disease is considerably larger in the 
former than in the latter month. This fact, which seems to show that the 
prevalence of the summer diarrhoea does not correspond with the degree of 



788 INTESTINAL CATARRH OF INFANCY. 

atmospheric heat, is readily explained. The mortality in October, and indeed 
in the latter part of September, is not that of new cases, but is mainly of 
infants, as I have observed every year, who contract the disease in July or 
August or earlier, and linger in a state of emaciation and increasing weak- 
ness till they finally succumb, some even in cool weather. 

The fact is therefore undisputed, and is universally admitted, that the 
summer season, stated in a general way, is the cause of this annually recur- 
ring diarrhoeal epidemic. That atmospheric heat does not in itself cause 
the diarrhoea is evident from the fact that in rural districts there is the same 
intensity of heat as in cities, and yet the summer complaint does not occur. 
The cause must be looked for in the state of the atmosphere engendered by 
heat where unsanitary conditions exist, as in large cities. Moreover, obser- 
vations show that the noxious effluvia with which the air becomes polluted 
under such circumstances constitute or contain the morbific agent. Thus, in 
one of the institutions of this city a few years since, on May 10th, which 
happened to be an unusually warm day for this month, an offensive odor was 
noticed in the wards, which was traced to a large manure heap that was being 
upturned in an adjacent garden. On this day four young children were 
severely attacked by diarrhoea, and one died. Many other examples might 
be cited showing how the foul air of the city during the hot months, when 
animal and vegetable decomposition is most active, causes diarrhoea. Several 
years since, while serving as sanitary inspector for the Citizens' Association in 
one of the city districts, my attention was particularly called to one of the streets, 
in which a house-to-house visitation disclosed the fact that nearly every 
infant between two avenues had diarrhoea, and usually in a severe form, not 
a few dying. The street was compactly built with wooden tenement-houses 
on each side, and contained a dense population, mainly foreigners, poor, 
ignorant, and filthy in their habits. It had no sewer, and the refuse of the 
kitchens and bed-chambers was thrown into the street, where it accumulated 
in heaps. Water trickled down over the sidewalks from the houses into the 
gutters or was thrown out as slops, so that it kept up a constant moisture of 
the refuse matter which covered the street, and promoted the decay of the 
animal and vegetable substances which it contained. The air in the domiciles 
and street under such conditions of impurity was necessarily foul in the 
extreme, and stifling during the hot days and nights of July and August ; 
and it was evidently the important factor in producing the numerous and 
severe diarrhoeal cases which were in these domiciles. 

In another locality, occupied by tripe-dealers and a low class of butchers 
who carried on fat- and bone-boiling at night, the air was so foul after dark 
that the peculiar impurity which tainted it could be distinctly noticed in the 
mouth for a considerable time after a night visit. In the street where these 
nuisances existed and in adjacent streets the summer diarrhoea was very 
prevalent and destructive to human life. Murchison states that 20 out of 25 
boys were aff'ected with purging and vomiting from inhaling the effluvia from 
the contents of an old drain near their school-room. Physicians are familiar 
with a similar fact showing this purgative effect of impure air — that the 
atmosphere of a dissecting-room often causes diarrhoea in those otherwise 
healthy. 

The impurities in the air of a large city are very numerous. Among those 
of a gaseous nature are sulphurous acid, sulphuric acid, sulphuretted hydro- 
gen ; various gases of the carbon group, as carbonic acid, carburetted hydrogen, 
and carbonic oxide ; gases of the nitrogen group, as the acetate, sulphide, 
and carbonate of ammonium, nitrous and nitric acids ; and at times com- 
pounds of phosphorus and chlorine (Parkes). A theory deserving consider- 
ation is that certain gaseous impurities found in the air form purgative com- 



ETIOLOGY, . 789 

binations. D. F. Lincoln, in his interesting paper on the atmosphere in the 
Cyclopaedia of Medicine^ writes in regard to sulphuretted hydrogen : " When 
in the air, freely exposed to the contact of oxygen, it becomes sulphuric acid. 
Sulphide of ammonium in the same circumstances becomes a sulphate, 
which, encountering common salt (chloride of sodium), produces sulphate of 
sodium and chloride of ammonium. The sulphates form a characteristic 
ingredient of the air in manufacturing districts." The sulphates, we know, 
are for the most part purgatives, but whether they or other chemical agents 
exist in the respired air in sufficient quantity to disturb the action of the 
intestines, even where atmospheric impurities are most abundant, is problem- 
atical and uncertain. 

Again, the solid impurities in the air of a large city are ver}^ numerous, 
as any one may observe by viewing a sunbeam in a darkened room which is 
made visible by the numerous particles floating in it. These particles consist 
largely of organic matter, which sometimes has been carried a long distance 
by the wind. The remarkable statement has been made that in the air of 
Berlin organic forms have been found of African production. Ehrenberg 
discovered fragments of insects of various kinds — rhizopods, tardigrades, 
polygastrics, etc. — which, existing in considerable quantity and inhaled in 
hot weather when decomposition and fermentation are most active, may be 
deleterious to the system. Monads, bacteria, vibriones, amorphous dust con- 
taining spores which retain their vitality for months, are among the substances 
found in the air of cities. The well-known hazy appearance of the atmosphere 
resting over a large city like New York when viewed from a distance is due 
to the gaseous and solid impurities with which the air is so abundantly sup- 
plied — impurities which assume importance in pathological studies, since 
minute organisms are now believed to cause so many diseases the etiology of 
which has heretofore been obscure. There can be no reasonable doubt, from 
recent investigations, that the deleterious agents which cause the form of 
diarrhoea which we are considering are to a great extent bacteria, which find a 
soil most favorable for their propagation where the air as well as ingesta con- 
tains impurities. In foul air, as in the summer season, in the crowded parts 
of the city, and especially where decomposing animal and vegetable matter 
exists, the number of micro-organisms is vastly greater, as different observers 
have remarked, than in salubrious localities. Foul air and unwholesome food 
— food that has begun to undergo decomposition or that digests with difficulty, 
so that part of it ferments — afford the conditions which are eminently favor- 
able for the development of pathogenic as well as non-pathogenic germs. We 
have seen that Booker and Yaughan have found bacteria in diarrhoeal stools 
which when isolated by cultivation either kill or cause intestinal catarrh in 
animals experimented on, or the ptomaines produced by the bacteria have 
this effect. The evidence, therefore, is strong that bacteria are the chief 
causal agents of those forms of diarrhoea which originate from foul air and 
unwholesome and indigestible food. 

In those portions of our cities which are occupied by the poor more than 
anywhere else those conditions prevail which render the atmosphere foul and 
unwholesome. One accustomed to the pure air of the country would scarcely 
believe how stifling and poisonous the atmosphere becomes during the hot 
summer days and close summer nights in and around the domiciles in the 
poor quarters of the city. Among the causes of this foul air may be men- 
tioned too dense a population, the occupancy of small rooms by large families, 
rigid economy and ceaseless endeavor to make ends meet, so that in the 
absorbing interest sanitary requirements are sadly neglected. Adults of such 
families, and children of both sexes as soon as they are old enough, engage 
in laborious and often filthy occupations. Many of them seldom bathe, and 



790 INTESTINAL CATARRH OF INFANCY. 

they often wear for days the same under-garments, foul with perspiration and 
dirt. The intemperate, vicious, and indolent, who always abound in the quar- 
ters of the city poor, are notoriously filthy in their habits and add to the insa- 
lubrity by their presence. Children old enough to be in the streets and adults 
away at their occupations escape to a great extent the evil effects of impure 
air, but the infantile population always suffer severely. 

Every physician who has witnessed the summer diarrhoea of infants is 
aware of the fact that the mode of feeding has much to do with its occur- 
rence. A large proportion of those who each summer fall victims to it 
would doubtless escape if the feeding were exactly proper. In New York 
City facts like the following are of common occurrence in the practice of all 
physicians : Infants under the age of eight months, if bottle-fed, nearly 
always contract diarrhoea, and usually of an obstinate character, during the 
summer months. The younger the infant, the less able is it to digest any 
other food than breast-milk, and the more liable is it therefore to suffer from 
diarrhoea if bottle-fed. In the institutions nearly every bottle-fed infant 
under the age of four or even six months dies in the hot months with symp- 
toms of indigestion and intestinal catarrh, while the wet-nursed of the same 
ages remain well. Sudden weaning, the sudden substitution of cow's milk 
or an artificially prepared food in place of breast-milk in hot weather, almost 
always produces diarrhoea, often of a severe and fatal nature. Feeding an 
infant in the hot months with indigestible and improper food, as fruits with 
seeds or the ordinary table food prepared in such a way that it overtaxes the 
digestive function of the infant, causes diarrhoea, and not infrequently that 
severe form of it which will be described under the term cholera infantum. 
Many obstinate cases of the summer complaint begin to improve under 
change of diet, as by the substitution of one kind of milk for another 
or the return of the infant to the breast after it has been temporarily 
withdrawn from it. It is a common remark in the families of the city poor 
that the second summer is the period of greatest danger to infants. This 
increased liability of infants to contract diarrhoea in the second summer 
is due to the fact that most infants in their second year are table-fed, while 
in the first year they are wet-nursed. Such facts, with which all physicians 
are familiar, show how important the diet is as a factor in causing the sum- 
mer complaint. 

Occasionally, from continued ill-health, the milk of the mother or wet- 
nurse does not agree with the nursling. Examined with the microscope, 
it is found to contain colostrum. Under such circumstances if a healthy 
wet-nurse be employed the diarrhoea ceases. It is very important that any 
woman furnishing breast-milk to an infant should lead a quiet and regular 
life, with regular meals and sleep. E. B. Gilbert^ relates striking cases in 
which venereal excesses on the part of wet-nurses were immediately followed 
by fatal diarrhoea in the infants whom they suckled. 

One not a resident would scarcely be able to appreciate the difiiculty 
which is experienced in a large city in obtaining proper diet for young chil- 
dren, especially those of such an age that they require milk as the basis of 
their food. Milk from cows stabled in the city or having a limited pastur- 
age near the city, and fed upon a mixture of hay with garden and distillery 
products, the latter often largely predominating, is unsuitable. It is defici- 
ent in nutritive properties, prone to fermentation, and from microscopical and 
chemical examinations which have been made it appears that it often con- 
tains deleterious ingredients. If milk be obtained from distant farms, where 
pasturage is fresh and abundant — and in New York City this is the usual 
source of the supply — considerable time elapses before it is served to cus- 
1 Louisville Med. Journal, Aug. 19, 1882. 



ETIOLOGY. 791 

tomers, so that, particularly in the hot months of July and August, it fre- 
quently has begun to undergo lactic-acid fermentation when the infants 
receive it. That dispensed to families in the morning is the milking of the 
previous morning and evening. The use of this milk in midsummer by 
infants under the age of ten months frequently gives rise to more or less 
diarrhoea. 

The ill-success of feeding with cow's milk has led to the preparation of 
various kinds of food which the shops contain, but no dietetic preparation has 
yet appeared which agrees so well with the digestive function of the infant as 
breast-milk, and is at the same time sufl&ciently nutritive. 

In New York City improper diet, unaided by the conditions which hot 
weather produces, is a common cause of diarrhoea in young infants, for at all 
seasons we meet with this diarrhoea in infants who are bottle-fed ; but when 
the atmospheric conditions of hot weather and the use of food unsuitable for 
the age of the infant are both present and operative, this diarrhoea so increases 
in frequency and severity that it is proper to designate it the summer epidemic 
of the cities. Several years since, before the New York Foundling Asylum 
was established, the foundlings of New York, more than a thousand annually, 
were taken to the almshouse on Blackwell's Island and consigned to the care 
of pauper-women, who were mostly old, infirm, and filthy in their habits and 
apparel. Their beds, in which the foundlings were also placed alongside of 
them, were seldom clean, not properly aired and washed, and under the beds 
were various garments and utensils which these pauper- worn en had brought 
with them as their sole property from their miserable abodes in the city. 
With such surroundings the air which these infants breathed day and night 
manifestly contained poisonous emanations, while their diet was equally 
improper, for it was prepared by these women from such milk and farinaceous 
food as were furnished the almshouse. Wlien assigned to duty in the alms- 
house, this service being at that time a branch of Charity Hospital. I was 
informed that all the foundlings died before the age of two months ; one only 
was pointed out as a curiosity which had been an exception to the rule. The 
disease of which they perished was diarrhoea, and this malady in the summer 
months was especially severe and rapidly fatal. The unpleasant experiences 
in this institution furnished additional evidence, were any wanting, that foul 
air and improper diet are the two important factors in causing the summer 
diarrhoea of infants. Since that beneficial charity, the New York Foundling 
Asylum, in East Sixty-eighth street, came into existence, providing pure air 
and, for a considerable proportion of the foundlings, breast-milk, many of 
these waifs have been rescued from death. 

Age. — Age is a predisposing cause of diarrhaea, since most cases occur 
under the age of three years. A large majority of the summer diarrhoeas of 
the cities occur under the age of two years. The following table embraces 
all the cases that came to one of the city dispensaries during my service 
between the months of May and October, inclusive: 

Age. Cases. 

5 months or under . 58 

5 months to 12 months 212 

12 months to 18 months 174 

18 montlis to 24 months 93 

24 months to 36 months 36 

Total 573 

Dentition. — Statistics show that by far the largest number of cases occur 
during the period of first dentition ; hence the prevalent opinion among fam- 
ilies that dentition causes the diarrhoea. It is the common belief among the 



792 INTESTINAL CATARRH OF INFANCY. 

poor of New York that diarrhoea occurring during dentition is conservative, 
and should not be checked. They believe that an infant cutting its teeth suf- 
fers less, and may be saved from serious illness, if it have frequent stools. 
Every summer I see infants reduced to a state of imminent danger through 
the continuance of diarrhoea during several weeks, nothing having been done 
to check it in consequence of this absurd belief. The progressive loss of flesh 
and strength and wasting of the features do not excite alarm, under the blind- 
ing influence of this theory, till the diarrhoea has continued so long and 
become so severe that it is with difiiculty controlled, and the patient is in a 
state of real danger when the physician is first summoned. The following 
statistics, which comprise cases occurring during my service in one of the city 
dispensaries, show the preponderance of cases during the age when dental 
evolution is occurring : 

Cases. 

No teeth and no marked turgescence of gums -47 

Cutting incisors 106 

Cutting anterior molars 41 

Cutting canines 40 

Cutting last molars 20 

All the teeth cut 28 

Total 282 

It so happens that the period of dental evolution corresponds with that of 
the most rapid development and the greatest functional activity of the gastric 
and intestinal follicles, and the predisposition which exists to diarrhoeal mala- 
dies at this age must be attributed to this cause rather than to dentition. 

Symptoms. — The intestinal catarrh of infancy commonly begins gradually 
with languor, fretfulness, and slight rise of temperature. The diarrhoea at 
first usually attracts little attention from its mildness. The stools, while they 
are thinner than natural, vary in appearance, being yellow, brown, or green. 
Infants with milk diet usually pass green and acid stools containing particles 
of indigested casein. The tongue in the commencement of the attack is moist 
and covered with a slight fur. At a more advanced stage it may be moist, 
but is often dry, and in dangerous forms of the malady, accompanied by pros- 
tration, the buccal surface is red and the gums more or less swollen and some- 
times ulcerated. Vomiting is common. It may commence simultaneously 
with the diarrhoea, especially when food that is unusually indigestible and 
irritating to the stomach has been given, but more frequently this symptom 
does not appear until the diarrhoea has continued a few days. I preserved 
memoranda of the date when vomiting began in the cases treated in two con- 
secutive years, and found that ordinarily it was toward the close of the first 
week. When it is an early and prominent symptom it appears to be due to 
the presence in the stomach of imperfectly digested or fermented and acid 
food, which, when ejected, gives a decidedly acid reaction with appropriate 
tests. It contains coagulated casein and undigested particles of whatever 
food has been given. In many patients the progressive loss of flesh and 
strength is largely due to the indigestion and vomiting, by which the food, 
which is so much required for proper nourishment, is lost. 

Emesis occurring at a late stage of infantile diarrhoea is often due to 
commencing spurious hydrocephalus, which is not an infrequent complica- 
tion, as we will see, of protracted cases. Perhaps when a late symptom it 
may sometimes have an ursemic origin, for the urine is usually quite scanty 
in advanced cases. It seems probable, however, that deleterious eff'ects 
from non-elimination of urea are to a considerable extent prevented by the 
diarrhoea. 

The fecal evacuations may remain nearly uniform in appearance during 



SY3IPT0MS. 793 

the disease, but in many patients they vary in color and consistence at differ- 
ent periods. In the same case they may be brown and offensive at one time, 
green at another, and again they may contain masses of a putty-like appear- 
ance, the partly-digested casein or altered epithelial cells. The stools some- 
times consist largely of mucus, with or without occasional streaks of blood, 
indicating the predominance of inflammation in the colon. This is the 
mucous diarrhoea of Barrier. The stools are sometimes yellow when passed, 
but become green on exposure to the air from chemical reaction due to 
admixture with the urine, or to the agency of the microbe mentioned above 
that produces green coloring matter. 

The character of the alvine discharges is interesting. In addition to 
undigested casein I have found epithelial cells, single or in clusters (some- 
times regularly arranged as if detached in mass from the villi), fibres of 
meat, crystalline formations, mucus, and occasionally blood, as stated above. 
In one instance I observed an appearance resembling three or four crypts of 
Lieberktihn united, probably thrown off by ulceration. If the stools are 
green, colored masses of various sizes, but mostly small, are also seen under 
the microscope. 

The pulse is accelerated according to the severity of the attack. The 
heat of the surface is at first generally increased, though but slightly in 
ordinary cases ; but when the vital powers begin to fail from the continuance 
of the diarrhoea, the warmth of the surface diminishes. In advanced cases 
approaching a fatal termination the face and extremities are pallid and 
cool, and the pulse gradually becomes more frequent and feeble. The skin 
is usually dry, and, as already stated, the urinary secretion diminished. In 
severe cases attended by frequent alvine discharges the infant does not pass 
urine oftener than once or twice daily. The imperfect action of the skin 
and kidneys is noteworthy. 

Protracted cases of diarrhoea are frequently complicated by two cutaneous 
eruptions — erythema extending over the perineum and frequently as far as 
the thighs and lower part of the abdomen, due to the acid and irritating cha- 
racter of the stools ; and boils upon the forehead and scalp. The latter some- 
times extend to the pericranium, and in case of recovery leave permanent 
cicatrices. This furuncular affection of the scalp has seemed to me useful 
in consequence of the external irritation which it causes, since it occurs 
at a time when, on account of the feeble heart's action and languid circula- 
tion, passive congestion of the vessels of the brain and meninges is liable 
to be present. 

Patients who are weak and wasted in consequence of protracted diar- 
rhoea, remaining almost constantly in the recumbent position, often have an 
occasional dry cough which continues till the close of life. It is due to 
hypostatic congestion in the lungs, usually limited to the posterior and infe- 
rior portions of the lobes, extending but a little way into the lungs. It is 
the result of prolonged recumbency with feeble heart's action and feeble 
pulmonary circulation. Infants reduced by chronic diseases, lying day after 
day in their cribs, with little movement of their bodies, are very liable to 
this passive congestion of depending portions of their lungs, toward which 
the blood gravitates, and into which iDut little air enters in consequence of 
their distance and position and the feeble respirations. The hyperaemia 
which results .is of a passive character, a venous congestion, and the affected 
lobules have a dusky-red color. This congestion, continuing, soon results in 
pneumonia of the catarrhal form, subacute and of a low grade, for pulmo- 
nary lobules in which the blood remains stagnant soon exhibit augmented 
cell-proliferation, perhaps from the irritating effects of the elements of the 
blood now withdrawn from the circulation. 



794 INTESTINAL CATARRH OF INFANCY. 

I have made or procured a considerable number of microscopic examina- 
tions in these cases of hypostatic pneumonia, and the solidification of the 
pulmonary lobules has been found to be due to the exaggerated development 
of the epithelial cells in the alveoli, together with venous congestion. The 
affected lobules, whether in a stage of hypostatic congestion or the more 
advanced stage of hypostatic pneumonia, when examined at the autopsy 
were somewhat softer than in health, of dark color, and many of the lob- 
ules could be inflated by strong force of the breath ; but in protracted cases 
the alveoli in central parts of the inflamed area resisted insufflation. The 
lung in hypostatic pneumonia, even when it is inflated, still feels firmer 
between the fingers than the normal lung. 

Hypostatic pneumonia is so common in hospitals for infants that some 
physicians whose observations have been chiefly in such institutions have 
almost ignored other forms of pulmonary inflammation. Billard many years 
ago wrote : " . . . . The pneumonia of young children is evidently the 
result of stagnation of blood in their lungs. Under these circumstances the 
blood may" be regarded as a kind of foreign body." Of all the chronic and 
exhausting diseases of infancy, no one has, according to my observations, 
been so frequently complicated by hypostatic pneumonia as the disease which 
we are considering, although it does not usually give rise to any more prominent 
symptom than an occasional cough. Limited to a small and almost immov- 
able part of the lung, it does not ordinarily accelerate respiration or render 
it painful, and the cough is also apparently painless. 

When the progressive loss of flesh and strength has continued several 
weeks and the patient is much exhausted, another complication is liable to 
occur, known as spurious hydrocephalus or the hydrocephaloid disease, the 
anatomical characters of which will be described in the proper place. The 
commencement of spurious hydrocephalus is announced by gradually increas- 
ing drowsiness, perhaps preceded by a period of fretfulness. Vomiting and 
rolling the head are occasional early symptoms of this complication. As the 
drowsiness increases the pupils become less sensitive to light than in their 
normal state, and are usually contracted. When the drowsiness becomes 
profound and constant the pupils remain contracted as in sound sleep or in 
opium narcotism. The functional activity of the organs is now also dimin- 
ished, the vomiting ceases, the stools become less frequent, the buccal surface 
dry, and the urine scanty, while the pulse is frequent and feeble. Spurious 
hydrocephalus either continues till death or by stimulation the patient may 
emerge from it. When profound the usual result is death. 

Although infantile diarrhoea in its commencement may be promptly 
arrested by proper hygienic and medicinal treatment, if it continue a few 
weeks the anatomical changes which occur are such that recovery, if it take 
place, is necessarily slow and gradual. Improvement is shown by better 
digestion, fewer stools and of better appearance, less frequent vomiting, a 
more cheerful countenance, and the absence of symptoms which indicate a. 
complication. Many recover after days of anxious watching and perhaps 
after many fluctuations. 

Death may occur early from a sudden aggravation of symptoms and rapid 
sinking, or the attack may be so violent from the first that the infant quickly 
succumbs ; but more frequently death takes place after a prolonged sickness. 
Little by little the patient loses flesh and strength till a state of marked 
emaciation is reached. The eyes and cheeks are sunken, the bony projections 
of the face, trunk, and limbs become prominent, and the skin lies in wrinkles 
from the wasting. The altered expression of the face makes the patient 
look older than the actual age. The joints in contrast with the wasted 
extremities seem enlarged and the fingers and toes elongated. The stools 



ANATOMICAL CHARACTERS. 795 

diminish in frequency from diminished peristaltic and vermicular action, and 
vomiting, if previously present, now ceases. A feeble, quick, and scarcely 
appreciable pulse, slow respiration, and diminished inflation of the lungs, 
sightless and contracted pupils, over which the eyelids no longer close, 
announce the near approach of death. The drowsiness increases and the 
limbs become cool, while perhaps the head is hot. The infant no longer has 
the ability to nurse, or if bottle-fed the food placed in the mouth flows back 
or is swallowed with apparent indiff'erence. So low is its vitality that it lies 
pallid and almost motionless for hours or even days before death, and death 
occurs so quietly that the moment of its occurrence is scarcely appreciable. 

Anatomical Characters. — Since the prominent and essential symptoms 
of the disease which we are considering pertain to the digestive apparatus, 
it is evident that the lesions which attend and characterize it are to be found 
in this part of the system. Lesions elsewhere, so far as they are appreciable 
to us, are secondary and not essential. I have witnessed a large number of 
autopsies of infants who have perished from diarrhoea, chiefly in institutions, 
and they have been sufl&ciently marked and uniform to enable us to desig- 
nate it an entero-colitis. Several years since I preserved records of the 
autopsical appearances in the intestinal catarrh of infants, most of them being 
cases of summer diarrhoea. The number aggregated eighty-two. Since then 
I have witnessed many autopsies in institutions in cases of this disease, and 
the lesions observed were similar to those in the eighty-two cases. 

The question may properly be asked. Can inflammatory hypergemia of the 
intestinal mucous membrane be distinguished from simple congestion if there 
be no ulceration and no appreciable thickening of the intestine? It is pos- 
sible that occasionally I have recorded as inflammatory what was simply a 
congestive lesion, but I do not think I have incorporated a sufficient number 
of such cases to vitiate the statistics. In a large proportion of the cases 
there was evident thickening of the intestinal mucous membrane or other 
"unequivocal evidence of inflammation. The following is an analysis of the 
82 cases: The duodenum and jejunum presented the appearance of inflam- 
matory hyperaemia in 12 cases. The hyperaemia was usually in patches of 
variable extent or of that form described by the term arborescent. In 51 
cases the duodenal and jejunal mucous membrane was pale and without any 
other appearance characteristic of catarrh or inflammation. In the remain- 
ing 19 cases the appearance of the duodenum and jejunum was not recorded, 
so that it was probably normal. On the other hand, in the ileum inflam- 
matory lesions were present as a rule. In 49 cases I found the surface of 
the ileum distinctly hyperaemic, and in that portion of it nearest the ileo- 
caecal valve, including the valve itself, the inflammation had evidently been 
the most intense, since in this portion the hyperaemia and thickening of the 
mijcous membrane were most marked. In 1(3 cases the surface of the ileum 
appeared nearly or quite normal ; in 14 hyperaemia in the small intestines in 
patches, streaks, or arborescence was recorded, but the records do not state 
in which division of the intestines they were observed. 

Billard, with other observers, has noticed the frequency and intensity of 
the inflammatory lesions in entero-colitis in the terminal portion of the small 
intestines, and thickening in many cases of the ileo-caecal valve, and he 
asks whether the vomiting which is so common and often obstinate in this 
disease may not be sometimes due to obstruction to the passage of fecal 
matter at the valve in consequence of its hyperaemia and swelling, but he has 
not observed any retained fecal matter above it, such as we find in any part 
of the colon, or any other appearance which indicated sufficient obstruction 
to cause symptoms. But it seems not improbable that the reason why the 
inflammatory lesions are more pronounced at and immediately above the 



796 INTESTINAL CATARRH OF INFANCY. 

vaive than in other parts of the small intestine is that the fecal matter, so 
commonly acid and irritating in this disease, is somewhat delayed in its pas- 
sage downward at this point. 

Small superficial circular or oval ulcers were observed in the ileum in 4 
cases, in 2 of which they were found also in the lower part of the jejunum. 
In 1 case the records state that ulcers were in the jejunum, but do not men- 
tion whether they were also in the ileum. In 1 case, in which there was 
much thickening of the ileum next to the ileo-c^ecal valve, many small gran- 
ulations had sprouted up from the submucous connective tissue, so that the 
mucous surface appeared as if studded with small warts. 

Softening of the mucous membrane was also apparent in certain cases. 
The firmness of its attachment to the parts underneath varied considerably 
in different specimens. I was able in cases in which there was considerable 
softening to detach readily the mueous membrane with the nail or handle of 
the scalpel within so short a period after death that it was probable that the 
change of consistence was not cadaveric. In some cases the vessels of the 
submucous tissue were injected and this tissue infiltrated. 

In all the cases except one, lesions were present indicating inflammation 
of the mucous membrane of the colon. In 39 hyperaemia, thickening, and 
other signs of inflammation extended over nearly or quite the entire colon ; 
in 14 the colitis was confined to the descending portion entirely or almost 
entirely ; in 28 cases the records state that inflammatory lesions were found 
in the colon, but their exact location is not mentioned. In 18 of the autop- 
sies the mucous membrane of the colon was found ulcerated. 

Therefore, according to these statistics — and autopsies which I have wit- 
nessed that are not embraced in them disclosed similar lesions — colitis is 
present, almost without exception, in cases of summer diarrhoea, associated 
with more or less ileitis. The portion of the colon which presents the most 
marked inflammatory lesions is that in and immediately above the sigmoid 
flexure — that portion, therefore, in which any fermenting fecal matter has 
reached its greatest degree of fermentation, and consequently contains the 
most irritating elements, and where, next to the caput coli, it is longest 
delayed in its passage downward. 

The solitary glands of both the large and small intestines and Peyer's 
patches undergo hyperplasia. In cases of short duration and in parts of 
the intestine where the inflammatory action has been mild, the solitary glands 
present a vascular appearance, like the surrounding membrane, and are slightly 
enlarged. The enlargement is most apparent if the intestine be viewed by 
transmitted light, when not only are the glands seen to be swollen, but their 
central dark points are distinct. If a higher grade of intestinal catarrh or a 
catarrh more protracted have occurred, the volume of these follicles is so 
increased that they rise above the common level and present a papillary 
appearance. Peyer's patches are also distinct and punctate. The enlarge- 
ment of Peyer's patches, like that of the solitary glands, is due to hyperpla- 
sia, the elementary cells being largely increased in number. 

The small ulcers which, as we have seen from the above statistics, are 
present in a certain proportion of cases in the mucous membrane of the 
colon, and more rarely in that of the small intestine when the inflammation 
has been protracted and of a severe type, appear to occur in the solitary 
glands and in the mucous membrane surrounding them. While some of 
these glands in a specimen are simply tumefied, others are slightly ulcerated,, 
and others still nearly or quite destroyed. The ulcers are usually from one 
to three lines in diameter, circular or oval, with edges slightly raised from 
infiltration. Rarely, I have seen minute coagula of blood in one or more 
ulcers, and I have also observed ulcers which have evidently been larger and 



ASATOMICAL CHARACTERS. 797 

have partially healed. The ulcers are more frequently found in the descend- 
ing colon than in other portions of the intestines. When ulcers are present 
they commonly occur in the descending colon, or if occurring elsewhere they 
are most abundant in this situation. 

According to my observations, these ulcers are found chiefly in infants 
over the age of six months — during the time, therefore, when there is great- 
est functional activity and most rapid development of the solitary glands. 
Peyer's patches, though frequently prominent and distinct, have not been 
ulcerated in any of the cases observed by me. 

The appendix vermiformis participates in the catarrh when it occurs in 
the caput coli, its mucous membrane being hyperaemic and thickened. In 
certain rare cases the inflammation is so intense that a thin film of fibrin is 
exuded in places upon the surface of the colon. It is liable to be overlooked 
or washed away in the examination. The rectum usually presents no inflam- 
matory lesions, or but slight lesions in comparison with those in the colon. 
It remains of the normal pale color, or is but slightly vascular in most 
patients, even when there is almost general colitis. Hence the infrequency 
of tenesmus. If tenesmus be present, probably the rectum participates in 
the inflammation. 

As might be expected from the nature of the disease, the secretion of 
mucus from the intestinal surface is augmented. It is often seen forming a 
layer upon the intestinal surface, and it appears in the stools mixed with epi- 
thelial cells and sometimes with blood and pus. 

The mesenteric glands in cases which have run the most protracted course 
and ended fatally are found more or less enlarged from hyperplasia. They 
are frequently as large as a pea or larger, and of a light color, the color being 
due not only to the hyperplasia, but in part to the anaemia. Occasionally, 
when patients have been much reduced from the long continuance of diar- 
rhoea, and are in a state of marked cachexia before death, we find certain of 
these glands caseous. 

The state of the stomach is interesting, since indigestion and vomiting are 
so commonly present. I have records of its appearance in 59 cases, in 42 
of which it seemed normal, having the usual pale color, and exhibiting only 
such changes as occur in the cadaver. In the remaining 17 cases the stom- 
ach was more or less hyperaemic, and in 3 of them points of ulceration were 
observed in the mucous membrane. 

All physicians familiar with this disease have remarked the frequency of 
stomatitis. In protracted and grave cases it is a common complication. The 
buccal surface in these cases is more vascular than natural, and if the vital 
powers are much reduced superficial ulcerations are not infrequent, oftener 
upon the gums than elsewhere. The gums are frequently spongy, more or 
less swollen, bleeding readily when rubbed or pressed. Thrush is a com- 
mon complication of protracted diarrhoea in infants under the age of three or 
four months, but is infrequent in older infants. Occurring in those over the 
age of six or eight months, it has an unfavorable prognostic significance, indi- 
cating a form of diarrhoea which commonly eventuates in death. 

The belief has long been prevalent in the past that the liver is also in 
fault. The green color of the stools was supposed to be due to vitiated bile. 
But usually in the post-mortem examinations which I have made I have 
found that the green coloration of the fecal matter did not appear at the 
point where the bile enters the intestines, but at some point below the ductus 
communis choledochus, in the jejunum or ileum. The green tinge, at first 
slight, becomes more and more distinct on tracing it downward in the intes- 
tine. The manner in which it is produced has been treated of elsewhere. 

I have notes of the appearance and state of the liver in 32 fatal cases. 



798 



INTESTINAL CATARRH OF INFANCY. 



Nothing could be seen in these examinations which indicated any anatomical 
change in this organ that could be attributed to the diarrhoeal malady. The 
size and weight of the liver varied considerably in infants of the same age, 
but probably there was no greater difference than usually obtains among 

The following was the weight of this 



glandular organs in a state of health 
organ in 20 cases : 



Age. Weight. 

4 weeks 5 ounces. 

2 months 2,h " 



3^ 
5 

9 

4* 
6" 



10] 


Tion 


ths 


13 






14 






15 






15 






15 






16 






19 






20 






23 







Weight. 
6| ounces. 
6 
9 
6 

n " 

9i '' 
6 

n " • 

15 



In none of these cases did the size, weight, or appearance of this organ seem 
to be diiferent from that in health or in other diseases, except in one in which 
fatty degeneration had occurred, but this was probably due to tuberculosis, 
which was also present. In most of these cases the liver was examined 
microscopically, and the only noteworthy appearance observed was the 
variable amount of oil-globules in the hepatic cells. In some specimens the 
oil-globules were in excess, in others deficient, and in others still they were 
more abundant in one part of the organ than in another. Little importance 
was attached to these differences in the quantity of oily matter. 

Hypostatic congestion of the posterior portions of the lungs, ending if it 
continue in a form of subacute catarrhal pneumonia and giving rise to an 
occasional painless cough, has been described in the preceding pages. The 
character of the cough in connection with the wasting might excite suspicions 
of the presence of tubercles in the lungs ; but tubercles are rare in this dis- 
ease, and when present I should suspect a strong hereditary predisposition. 
They occurred in only 1 of the 82 cases. 

The state of the encephalon in those patients in whom spurious hydro- 
cephalus occurs is interesting. In protracted cases of diarrhoea the brain 
wastes like the body and limbs. In the young infant, in whom the cranial 
bones are still ununited, the occipital and sometimes the frontal bones become 
depressed and overlapped by the parietal, the depression being of course pro- 
portionate to the diminution in size of the encephalon. The cranium becomes 
quite uneven. In other children, with the cranial bones consolidated, serous 
effusion occurs according to the degree of waste, thus preserving the size of 
the encephalon. The effusion is chiefly external to the brain, lying over the 
convolutions from the base to the vertex. Its quantity varies from one or 
two drachms to an ounce or more. Along with this serous effusion, and ante- 
dating it, passive congestion of the cerebral veins and sinuses is also present. 
This congestion is the obvious and necessary result of the feebleness of the 
heart's action and the loss of brain-substance. 

Diagnosis. — In the adult, abdominal tenderness is an important diag- 
nostic symptom of intestinal catarrh, but in the infant this symptom is lack- 
ing or is not in general appreciable, so that it does not aid in diagnosis. 
When the diagnosis of the disease is established, the symptoms do not 
usually indicate what part of the intestinal surface is chiefly involved, but 
it may be assumed that it is the lower part of the ileum and the colon. The 
presence of mucus or of mucus tinged with blood in the stools shows the 
predominance of colitis. 



CHOLERA IXFAXTUM. 799 

Prognosis. — Although this disease largely increases the death-rate of 
young children, most cases can be cured if proper hygienic and medicinal 
measures be earl}' applied. It is obyious, from what has been stated in the 
foregoing pages, that cholera infantum is the form of this malady which 
inyolyes greatest danger. Except in such cases there is sufficient forewarn- 
ing of a fatal result, for if death occur it is after a lingering sickness, with 
fluctuations and gradual loss of flesh and strength. Patients often recoyer 
from a state of great prostration and emaciation, proyided that no fatal com- 
plications arise. The eyes may be sunken, the skin lie in folds from the 
wasting, the strength may be so exhausted that any other than the recumbent 
position is impossible, and yet the patient may recoyer by removal to the 
country, by change of weather, or by the use of better diet and remedies. 
Therefore an absolutely unfavorable prognosis should not be made except in 
cases that are complicated or that border on collapse. The most dangerous 
symptoms, except those which indicate commencing or actual collapse, arise 
from the state of the brain. Rolling the head, squinting, feeble action or 
permanent contraction of the pupils, spasmodic or irregular moyements of 
the limbs, indicate the near approach of death, as do also coldness of face 
and extremities and inability to swallow. It is obyious also, in making the 
prognosis in ordinary cases, that we should consider the age of the patient, 
and if the diarrhoea be that of the summer season, the state of the weather, 
the time in the summer, whether in the beginning or near its close, and the 
surroundings, especially in reference to the impurity of the air, as well as 
the patient's condition. 

Cholera Infantum, or Oholeriform Diarrhcea. 

This is the most severe form of infantile diarrhoea. It receives the name 
which designates it from the violence of its symptoms, which closely resemble 
those of Asiatic cholera. It is. however, quite distinct from that disease. 
It is characterized by frequent stools, vomiting, great elevation of tempera- 
ture, and rapid and great emaciation and loss of strength. It commonly 
occurs under the age of two years. It sometimes begins abruptly, the pre- 
vious health having been good ; in other cases it is preceded by the ordinary 
form of diarrhoea. The stools have been thinner than natural and somewhat 
more frequent, but not such as to excite alarm, when suddenly they become 
more frequent and watery, and the parents are surprised and frightened by 
the rapid sinking and real danger of the infant. 

The first evacuations, unless there have been previous diarrhoea, may 
contain fecal matter, but subsequently they are so thin that they soak into 
the diaper like urine, and in some cases they scarcely produce more of a stain 
than does this secretion. Their odor is peculiar — not fecal, but musty and 
offensive ; occasionally they are almost odorless. Commencing simultaneously 
with the watery evacuations or soon after is another symptom — irritability of 
the stomach, which increases greatly the prostration and danger. Whatever 
drinks are swallowed by the infant are rejected immediately or after a few 
moments, or retching may occur without vomiting. The appetite is lost and 
the thirst is intense. Cold water is taken with avidity, and if the infant 
nurse it eagerly seizes the breast in order to relieve the thirst. The tongue 
is moist at first, and clean or covered with a light fur, pulse accelerated, res- 
piration either natural or somewhat increased in frequency, and the surface 
warm, but its temperature is speedily reduced in severe cases. The internal 
temperature or that of the blood is always very high. In ordinary cases of 
cholera infantum the thermometer introduced into the rectum rises to or 
above 105^. and I have seen it indicate 107°. Although the infant may be 



800 INTESTINAL CATARRH OF INFANCY. 

restless at first, it does not appear to have any abdominal pain or tenderness. 
The restlessness is apparently due to thirst or to that unpleasant sensation 
which the sick feel when the vital powers are rapidly reduced. The urine is 
scanty in proportion to the gravity of the attack, as it ordinarily is when the 
stools are frequent and watery. 

The emaciation and loss of strength are more rapid than in any other dis- 
ease which I can recall to mind, unless in Asiatic cholera. In a few hours 
the parents scarcely recognize in the changed and melancholy aspect of 
the infant any resemblance to the features which it previously exhibited. 
The eyes are sunken, the eyelids and lips are permanently open from the 
feeble contractile power of the muscles which close them, while the loss of the 
fluids from the tissues and the emaciation are such that the bony angles 
become more prominent and the skin in places lies in folds. 

As the disease approaches a fatal termination, which often occurs in two 
or three days, the infant remains quiet, not disturbed even by the flies which 
alight upon its face. The limbs and face become cool, the eyes bleared, 
pupils contracted, and the urine scanty or suppressed. In some instances, 
when the patient is near death, the respiration becomes accelerated, either 
from the efl"ect of the disease upon the respiratory centres or from pulmonary 
congestion resulting from the feeble circulation. As the vital powers fail the 
pulse becomes progressively more feeble, the surface has a clammy coldness, 
the contracted pupils no longer respond to light, and the stupor deepens, from 
which it is impossible to arouse the infant. 

In the more favorable cases cholera infantum is checked before the occur- 
rence of these grave symptoms, and often in cases which are ultimately fatal 
there is not such a speedy termination of the malady as is indicated in the 
above description. The choleriform diarrhoea abates and the case becomes 
one of the ordinary summer complaint. 

Anatomical Characters. — Rilliet and Barthez, who of foreign writers 
treat of cholera infantum at greatest length, describe it under the name of 
gastro-intestinal choleriform catarrh. " The perusal," they remark, " of 
anatomico-pathological descriptions, and especially the study of the facts, 
show that the gastro-intestinal tube in subjects who succumb to this disease 
may be in four diff"erent states : («) either the stomach is softened without 
any lesion of the digestive tube ; (h) or the stomach is softened at the same 
time that the mucous membrane of the intestine, and especially its follicular 
apparatus, is diseased ; (c) or the stomach is healthy, while the follicular 
apparatus or the mucous membrane is diseased ; {d) or, finally, the gastro- 
intestinal tube is not the seat of any lesion appreciable to our senses in the 
present state of our knowledge, or it presents lesions so insignificant that they 
are not sufficient to explain the gravity of the symptoms. 

" So far, the disease resembles all the catarrhs, but what is special is the 
abundance of serous secretion and the disturbance of the great sympathetic 
nerve. 

" The serous secretion, which appears to be produced by a perspiration 
(analogous to that of the respiratory passages and of the skin) rather than 
by a follicular secretion, shows, perhaps, that the elimination of substances is 
effected by other organs than the follicles; perhaps, also, we ought to see a 
proof that the materials to eliminate are not the same as in simple catarrh. 
Upon all these points we are constrained to remain in doubt. We content 
ourselves with pointing out the fact." ^ 

On the 1st of August, 1861, I made the autopsy of an infant sixteen 
months old which died of cholera infantum with a sickness of less than one 
day. The examination was made thirty hours after death. Nothing unusual 

^ Maladies des Enfants. 



ANATOMICAL CHARACTERS. 801 

was observed in the brain, unless perhaps a little more than the ordinary 
injection of vessels at the vertex. No marked anatomical change was 
observed in the stomach and intestines, except enlargement of the patches of 
Peyer as well as of the solitary and mesenteric glands. Mucous membrane 
pale. In this and the following cases there was apparently slight softening 
of the intestinal mucous membrane, but whether it was pathological or 
cadaveric was uncertain, as the weather was very warm. The liver seemed 
healthy. Examined by the microscope, it was found to contain about the 
normal number of oil-globules. 

The second case was that of an infant seven months old, wet-nursed, who 
died July 26, 1862, after a sickness also of about one day. He was pre- 
viously emaciated, but without any marked ailment. The post-mortem 
examination was made on the 28th. The brain was somewhat softer than 
natural, but otherwise healthy. There was no abnormal vascularity of the 
membranes of the brain, and no serous effusion within the cranium. The 
mucous membrane of the intestines had nearly the normal color throughout, 
but it seemed somewhat thickened and softened ; the solitary glands of the 
colon were prominent. The patches of Peyer were not distinct. 

In the New York Protestant Episcopal Orphan Asylum an infant twenty 
months old, previously healthy, was seized with cholera infantum on the 25th 
of June, 1864. The alvine evacuations, as is usual with this disease, were 
frequent and watery and attended by obstinate vomiting. Death occurred in 
slight spasms in thirty-six hours. The exciting cause was probably the use 
of a few currants which were eaten in a cake the day before, some of which 
fruit was contained in the first evacuations. The brain was not examined. 
The only pathological changes which were observed in the stomach and intes- 
tines were slightly vascular patches in the small intestines and an unusual 
prominence of the solitary glands in the colon. The glands resembled small 
beads imbedded in the mucous membrane. The lungs in the above cases 
were healthy, excepting hypostatic congestion. 

Since the date of these autopsies I have made others in cases which 
terminated fatally after a brief duration, and have uniformly found similar 
lesions — to wit, the gastro-intestinal surface either without vascularity or 
scantily vascular in streaks or patches, sometimes presenting a whitish or soggy 
appearance and somewhat softened, while the solitary glands were enlarged 
so as to be prominent upon the surface. In cases which continue longer 
evident inflammatory lesions soon appear which are identical with those 
which have already been described in our remarks relating to the ordinary 
form of diarrhcea. 

During my term of service in the New York Foundling Asylum in the 
summer of 1884 an infant died after a brief illness with all the symptoms of 
cholera infantum, and the intestines were sent to William H. Welch, now of 
Johns Hopkins Hospital, for microscopic examination. His report was as 
follows : " I found undoubted evidence of acute inflammation. There was 
an increased number of small round cells (leucocytes) in the mucous and 
submucous coats. This accumulation of new cells was most abundant in 
and around the solitary follicles, which were greatly swollen. Clumps of 
lymphoid cells were found extending even a little into the muscular coat. 
The epithelial lining of the intestine was not demonstrable, but this is usu- 
ally the case with post-mortem specimens of human intestine, and justifies 
no inferences as to pathological changes. The glands of Lieberkiihn were 
rich in the so-called goblet-cells, and some of the glands were distended with 
mucus and desquamated epithelium, so as to present sometimes the appear- 
ance of little cysts. This was observed especially in the neighborhood of 
the solitary follicles. The blood-vessels, especially the veins of the sub- 

61 



802 INTESTINAL CATARRH OF INFANCY. 

mucous coat, were abnormally distended with blood. I searched for micro- 
organisms, and found them in abundance upon the free surface of the intes- 
tine, in mucous accumulations there, and also in the mouths of the glands 
of Lieberkiihn. Both rod-shaped and small round bacteria were found. I 
attach no especial importance to finding bacteria upon the surface of the 
intestine. The general result of the examination is to confirm the view that 
cholera infantum is characterized by an acute intestinal inflammation." 

Nature. — Cholera infantum appears from its symptoms and lesions to be 
the most severe form of intestinal catarrh to which infants are liable. The 
alvine discharges, to which the rapid prostration is largely due, probably con- 
sist in part of intestinal secretions, and in part of serum which has transuded 
from the capillaries of the intestines. That the intestinal mucous membrane 
sometimes presents a pale appearance at the autopsy of an infant who, pre- 
viously well, has died of cholera infantum after a sickness of twenty-four 
or forty-eight hours, is perhaps due to the great amount of liquid secretion 
and transudation in which the inflamed surface is bathed. Moreover, it is, I 
believe, a recognized fact that the hypen^mia of an acutely inflamed surface 
when of short duration frequently disappears in the cadaver, as that of scar- 
let fever and erysipelas. The early hyperplasia of the solitary and mesen- 
teric glands, and the hypergemia and thickening of the surface of the ileum 
and colon in those who have survived a few days, affords additional proof 
of the inflammatory character of the malady. 

The opinion has been expressed by certain observers that cholera infan- 
tum is identical with thermic fever or sunstroke. There is indeed a resem- 
blance to thermic fever as regards certain important symptoms. In cholera 
infantum the temperature is from 105° to 108° ; in sunstroke it is also very 
high, often running above 108°. Great heat of head, contracted pupils, thin 
fecal evacuations, embarrassed respiration, scanty urine, and cerebral symp- 
toms are common toward the close of cholera infantum, and they are the 
prominent symptoms in sunstroke. Nevertheless, I cannot accept the theory 
which regards these maladies as identical, and which removes cholera infan- 
tum from the list of intestinal diseases. In cholera infantum the gastro- 
intestinal symptoms always take the precedence, and are, except in advanced 
cases, always more prominent than other symptoms. It does not commence 
as by a stroke like coup de soleil, but it comes on more gradually, though 
rapidly, and it often supervenes upon a diarrhoea or some error of diet. In 
the commencement of cholera infantum the infant is usually not drowsy, 
and is often wide awake and restless from the thirst. Contrast this with the 
alarming stupor of sunstroke. Sunstroke only occurs during the hours of 
excessive heat, but cholera infantum may occur at any hour or in any day 
during the hot weather, provided that there be sufficient dietetic cause. 
Again, intestinal inflammation is not common in sunstroke, while it is the 
common, or, as I believe, the essential, lesion of cholera infantum. These 
facts show, in my opinion, that the two maladies are essentially and entirely 
distinct. Nevertheless, cases of apparent sunstroke sometimes occur in the 
infant, and if the bowels are at the same time relaxed the disease may be 
regarded as cholera infantum, and if fatal is usually reported as such to the 
health authorities. Cases of this kind I have occasionally observed or they 
have been reported to me, although they are not common. 

With the exception of the organs of digestion no uniform lesions are 
observed in any of the viscera in cholera infantum, except such as are due to 
change in the quantity and fluidity of the blood and its circulation. Writers 
describe an anaemic appearance of the thoracic and abdominal viscera, and 
occasionally passive congestion of the cerebral vessels. The cerebral symp- 
toms usually present toward the close of life in unfavorable cases of cholera 



DIA GNOSIS— TREA TMENT. 803 

infantum are often due to spurious hydrocephalus, which we have described 
above ; but as the urinary secretion is scanty or suppressed, cerebral symptoms 
may in certain cases be due to uraemia. 

Diagnosis. — This form of the summer diarrhoea is diagnosticated by the 
symptoms, and especially by the frequency and character of the stools. The 
stools have already been described as frequent, often passed with considerable 
force, deficient in fecal matter, and thin, so as to soak into the diaper almost 
like urine. The vomiting, thirst, rapid sinking, and emaciation serve to dis- 
tinguish cholera infantum from other diarrhoeal maladies. 

When Asiatic cholera is prevalent the differential diagnosis between the 
two is difficult if not impossible. 

Prognosis. — Cholera infantum is one of those diseases in regard to which 
physicians often injure their reputation by not giving sufficient notice of the 
danger, or even by expressing a favorable opinion when the case soon after 
ends fatally. A favorable prognosis should seldom be expressed without 
qualification. If the urgent symptoms be relieved, still the disease may con- 
tinue as an ordinary intestinal inflammation, which in hot weather is formid- 
able and often fatal. If the stools become more consistent and less frequent 
without the occurrence of cerebral symptoms, while the limbs are warm and 
the pulse good, we may confidently express the opinion that there is no pres- 
ent danger. 

The duration of true cholera infantum is short. It either ends fatally, or 
it begins soon to abate and ceases, or it continues and is not to be distin- 
guished in its subsequent course from an attack of summer diarrhoea begin- 
ning in the ordinar}^ manner. 

Treatment of Infantile Diarrh(ea. — Obviously, efficient preventive 
measures consist in the removal of infants so far as practicable from the ope- 
ration of the causes which produce the disease. Weaning just before or in 
the hot weather should, if possible, be avoided, and removal to the country 
should be recommended, especially for those who are deprived of breast-milk 
during the age when such nutriment is required. If for any reason it is 
necessary to employ artificial feeding for infants under the age of ten months, 
that food should obviously be used which most closely resembles human milk 
in digestibility and in nutritive properties. 

It is also very important that the infant receive its food in proper quan- 
tity and at proper intervals, for if the mother or nurse in her anxiety to have 
it thrive feed it too often or in too large quantity, the surplus food which it 
cannot digest, if not vomited, undergoes fermentation, and consequently 
becomes irritating to the gastro-intestinal surface. The physician should be 
able to give advice not only in reference to the frequency of feeding, but also 
in regard to the quantity of food which the infant requires at each feeding. 
Correct knowledge and advice in this matter aid in the prevention and cure of 
the diarrhoeal maladies of infancy. The reader is referred to the chapters 
relating to the feeding of infants. 

The indications for treatment are : 1st. To provide the best possible food 
which will afford sufficient nutriment and be easily digested ; 2d. To aid the 
digestive functions of the infant; 3d. To employ such medicinal agents as can 
be safely given to check the diarrhoea and cure the intestinal catarrh ; 4th. To 
procure fresh air, which is especially needed if the diarrhoea be that of the 
summer season. 

We will here repeat certain facts in reference to the feeding of infants 
which are of the highest importance in the treatment of the diarrhoeal mal- 
adies. Milk designed for the nursery should always be sterilized by the 
action of heat at or a little below the boiling-point, prolonged from one to two 
hours. I uniformly direct that the morning supply of milk designed for the 



804 INTESTINAL CATARRH OF INFANCY. 

infant be as soon as received placed in or over water in a steamer or other 
suitable vessel and subjected to a heat at or a little below 212° during two 
hours. This milk is used during the following twenty-four hours. Barley 
or wheat flour, subjected to the prolonged action of heat, by which its starch 
is changed more or less into dextrin, is also required. By the proper admix- 
ture of the farinaceous food with the milk the best possible diet for the 
bottle-fed infant will be obtained. The reader is referred to the appropriate 
chapters for details relating to infant feeding. 

The infant with intestinal catarrh, the prominent symptom of which is 
diarrhcea, is thirsty, and is therefore likely to take more nutriment in the 
liquid form than it requires for its sustenance. If wet-nursed it craves the 
breast, or if weaned it craves the bottle at short intervals. No more nutri- 
ment should be allowed than is required for nutrition, and the thirst may be 
best relieved by a little cold water, to which the white of egg is added, gum- 
water, or thin barley-water, containing a few drops of whiskey or brandy. 

In the dietetic treatment of the summer diarrhcea of the bottle-fed infant, 
in which not only diarrhoea but indigestion and vomiting are prominent symp- 
toms, I at first withhold cow's milk and allow only barley gruel, the barley 
flour having been previously subjected to the heat of boiling water seven days. 
If the infant exhibit evidences of innutrition, I add to the gruel designed for 
each feeding, when it is cool, the white of a fresh egg, the mixture contain- 
ing sufiicient salt to be tasted, and usually two to three drops of whiskey or 
brandy for each month of the infant's age. The feeding should be at inter- 
vals of three hours. This food should be at a temperature not higher than 
50° or 60° F., on account of the egg, and the infant readily takes it in con- 
sequence of the thirst if not from hunger. If it craves drink or more nutri- 
ment between the feedings, take one-third of a tumblerful of water previously 
boiled and its temperature reduced to 40° or 50°, and add to it the white of 
the egg, with a little brandy. The infant will take this readily, and if old 
enough to speak will ask for more. It is a good vehicle for the powder of 
bismuth and pepsin. With this diet the infant is sufficiently nourished for a 
week or more. At present (August, 1890) an infant whom I am attending 
takes the white of eight eggs in twenty-four hours. In a few days, when 
the vomiting and to a certain extent the diarrhoea are controlled, milk, pre- 
viously sterilized by heat and peptonized by peptogenic powder, may be 
cautiously added to the barley gruel in place of the egg — three tablespoonfuls 
for a child of five months, and five or six tablespoonfuls for one of twelve 
months. 

The occasional cases of infantile diarrhoea which result from taking cold 
require to be treated by the use of bland and easily-digested diet, and med- 
icines that are soothing and such as restrain the evacuations and relieve pain ; 
prominent among which remedies are bismuth and an opiate. But a large 
majority of the cases of diarrhoea in infancy arise, as we have seen, from 
improper feeding and insanitary conditions, and to these cases the following 
remarks apply. The summer diarrhoeal epidemics of the cities especially 
demand our attention on account of the large number that are afi"ected and 
the many deaths that result. 

We have seen that the two factors which produce the microbic diarrhoea 
of infancy, of which the summer epidemic of the cities is the type, are 
improper food and foul air. It is therefore obvious that measures should be 
employed to render the atmosphere in which the infant lives as free as pos- 
sible from noxious eflluvia. Cleanliness of the person, of the bedding, and of 
the house in which the patient resides, the prompt removal of all refuse ani- 
mal or vegetable matter, whether within or around the premises, and allowing 
the infant to remain a considerable part of the day in shaded localities where 



TREATMENT. 805 

the air is pure, as in the parks or suburbs of the city, are important measures. 
In New York great benefit has resulted from the floating hospital which every 
second day during the heated term carries a thousand sick children from the 
stifling air of the tenement-houses down the bay and out to the fresh air of 
the ocean. 

But it is difiicult to obtain an atmosphere that is entirely pure in a large 
city with its many sources of insalubrity ; and all physicians of experience 
agree in the propriety of sending infants affected with the summer diarrhoea 
to localities in the country which are free from malaria and sparsely inhab- 
ited, in order that they may obtain the benefits of purer air. Man}^ are the 
instances each summer in New York City of infants removed to the country 
with intestinal inflammation, with features haggard and shrunken, with limbs 
shrivelled and the skin lying in folds, too weak to raise (or at least hold) 
their heads from the pillow, vomiting nearly all the nutriment taken, with 
stools frequent and thin, resulting in great part from molecular disintegration 
of the tissues — presenting, indeed, an appearance seldom observed in any 
other disease except in the last stages of phthisis — and returning in late 
autumn with the cheerfulness, vigor, rotundity of health. The localities 
usually preferred by the physicians of this city are the elevated portions of 
New Jersey and Northern Pennsylvania, the Highlands of the Hudson, the 
central and northern parts of New York State, and Northern New England. 
Taken to a salubrious locality and properly fed, the infant soon begins to 
improve if the disease be still recent, unless it be exceptionally severe. If 
the disease have continued several weeks at the time of the removal, little 
benefit may be observed from the country residence iintil two or more weeks 
have elapsed. 

An infant weakened and wasted by the summer diarrhoea, removed to a 
cool locality in the country, should be warmly dressed and kept indoor 
when the heavy night dew is falling. Patients sometimes become worse 
from injudicious exposure of this kind, the intestinal catarrh from which 
they are suffering being aggravated by taking cold and perhaps rendered 
dysenteric. 

Sometimes parents, not noticing the immediate improvement which they 
have been led to expect, return to the city without giving the country fair 
trial, and the life of the infant is then, as a rule, sacrificed. Returned to 
the foul air of the city while the weather is still warm, it sinks rapidly from 
an aggravation of the malady. Occasionally, the change from one rural 
locality to another, like the change from one wet-nurse to another, has a salu- 
tary effect. The infant, although it has recovered, should not be brought 
back while the weather is still warm. One attack of the disease does not 
diminish, but increases, the liability to a second seizure. 

Medicinal Treatment. — Opiates. — It is evident that opiates are less used 
than formerly in the treatment of the microbic diarrhoeas of infancy. A 
proper appreciation of the pathology of these diarrhoeas naturally leads to 
the belief that the opiates are less important as curative agents than they 
were formerly supposed to be. Opiates diminish the peristalsis and the num- 
ber of stools, but they do not destroy the microbes or the ptomaines. Their 
use should, I think, be limited to cases of restlessness, of tenesmus, and of 
frequent watery stools. They may be useful in controlling symptoms till 
other remedies have time to act. One drop of laudanum or fifteen drops 
of paregoric may be given to an infant of ten months and repeated in three 
hours. I prefer paregoric to any other opiate in the treatment of the sum- 
mer diarrhoeas of infancy, since they are attended by marked prostration, and 
this agent is highly stimulating, from the camphor which it contains. 

Antiseptics. — Although the pathology of microbic diarrhoea suggests the 



806 INTESTINAL CATARRH OF INFANCY. 

use of antiseptics, my observations have not been favorable to the use of 
salol, naphthaline, or corrosive sublimate. They have seemed to me to do 
more harm than good. Guaita employs sodium benzoate. He administers 
in twenty-four hours one drachm or a drachm and a half in three ounces of 
water, with, it is stated, good results.^ The antiseptic which is more largely 
used than any other, and which more than any other has the confidence of 
the profession — and justly so — is the subnitrate of bismuth. It undergoes 
a chemical change in the stomach and intestines, becoming a bismuth sulphide 
and causing dark stools. It may be combined with chalk or pepsin, and 
should be given in doses of ten or twelve grains to an infant of six months. 

Irrigation of the Stomach. — Physicians of experience in New York and 
elsewhere recommend irrigation of the stomach with warm water in the 
treatment of malnutrition and gastro-intestinal catarrh. It removes from the 
stomach thick curds that digest with difficulty, as well as other aliment that 
may be undergoing gastric digestion. It has not, perhaps, been sufficiently 
employed to determine its full value, but from what I have seen of its effects 
I am not able to recommend it. The nutriment should be given so prepared 
and with such aids to digestion that the heavy casein curds do not form in 
the stomach. Moreover, the gastric juice is the one of the digestive fer- 
ments that is especially destructive to microbes, so that it is needed in the 
stomach for its germicide as well as digestive action. We have seen from 
the observations of Dr. Max Einhart that after two hours the stomach 
digestion of properly prepared milk or milk and barley gruel is completed, 
and the stomach in a state to receive more food. For these reasons irriga- 
tion of the stomach, habitually practised even in cases of indigestion or 
catarrh, seems to me more likely to be injurious than beneficial. On the 
other hand, when the stools are fermenting and imperfectly digested, and are 
accompanied by tenesmus, irrigation of the rectum frequently gives consid- 
erable relief. 

Alkalies. — Acids, especially the lactic and butyric products of faulty 
digestion, often collect in the stomach and intestines. These acids, which are 
active irritants, should be neutralized while we endeavor to prevent their 
production by improving the diet and aiding the digestion. In a few days 
the inflammatory irritation of the mucous follicles causes an exaggerated 
secretion of mucus, which is alkaline, and which neutralizes the acids to a 
considerable extent. An alkali is therefore required in most cases. It is 
especially useful when the infant has acid vomiting and acid stools. Lime- 
water, the sodium bicarbonate, and the various preparations of chalk are the 
antacids which by common consent are employed to neutralize the acids in 
the diarrhoeal maladies of infancy. My preference is for the mistura cretae, 
given midway between the nursings or feedings. An alkali is incompatible 
with pepsin, and as pepsin preparations are needed to assist digestion, they 
should not be given at the same time with the alkali. 

Astringents. — The vegetable astringents were formerly much used in the 
treatment of the diarrhoeal diseases of infancy, but they are now seldom pre- 
scribed for these cases. Even the mineral astringents, acetate of lead and 
nitrate of silver, have gone out of use in the treatment of the infantile diar- 
rhoeas. The alkalis and bismuth have taken their place. 

Stirmdanfs. — The diarrhoea, if severe, soon produces symptoms of pros- 
tration or heart failure, so that alcoholic stimulation is needed. Brandy or 
whiskey is the best stimulant in this disease — from ten to twenty-five drops 
according to the age every second hour. 

Occasionally it is proper to commence the treatment by the employment 
of some gentle purgative, especially when the diarrhoea begins abruptly after 
1 N. Y. Med. Record, May 31, 1884. 



TREATMENT, 807 



the use of irritating and indigestible food. A single dose of castor oil or 
syrup of rhubarb, or the two mixed, will remove the irritating substance, and 
afterward remedies designed to control the disease can be more successfully 
employed. 

The following are useful prescriptions : 

R. Bismuth, subnitrat., ,^i| ; 

Mistura cretse, Jij. Misce. 

Shake thoroughly, and give one teaspoonful every two hours to an infant of six to ten 
months. It should be administered midway between the feedings, for the reason 
stated above. 

R. Bismuth, subnitrat., ^jij ; 

Mucil. acaci?e, .^ss ; 

Aquse cinnamomi, 5iss. Misce. 

Shake bottle, and give one teaspoonful hourly until the vomiting and diarrhoea cease. 

Some physicians of large experience, as Prof. Henoch of Berlin, recom- 
mend small doses of calomel, as a twelfth or twentieth of a grain three or 
four times daily. If it be useful it probably acts as a germicide, but we 
have, it seems to me, more efficient and safer remedies, and I never pre- 
scribe it. 

It is very important in the treatment of the summer diarrhoea to aid 
digestion while we employ an antiseptic, and the following are formulse 
which I have employed with apparently the best results in family practice 
and in the institutions in New York : 

R. Acidi hydrochlorici dil., lU,^vj ; 

Pepsini puri, in lamellis,- ,^j ; 

Bismuthi subnitrat., .^ij ; 

Syi-upi, f^ij ; 

Aquae, f^xiv. Misce. 

Shake bottle. Give one teaspoonful before each feeding or nursing to an infant of ten 
months; half a teaspoonful to an infant of five months. 

R. Pepsini saccharati, ,^i-ij ; 

Bismuthi subnitrat.. ^ij. Misce. 
Divide in chart. No. xii. Give one powder before each nursing or feeding to an infant 
of ten months. 

R, Pepsini puri, in lamellis, ^] ; 

Bismutlii subnitrat., ,^ss ; 

Yini pepsini, N. F., ,^.ss; 

Aquae destillat., ,^iiiss. Misce. 

Shake bottle. Give one teaspoonful before each feeding to an infant at or above the 
age of six months; half a teaspoonful between the ages of two and six months. 

R. Pepsini puri, in lamellis, .^j ; 

Bismuthi subnitrat., ,^ss. Misce. 

Give as much as goes on a ten-cent piece or a five-cent nickel piece before each nursing 
or feeding. 

If the diarrhoea and vomiting have ceased, but the digestion be slow and 
incomplete, the following prescriptions will be found useful : 

R. Pepsini puri, in lamellis, 7^] ; 

Lactopeptone, 3ss. 

Give as much as will go on a ten-cent piece or as much as will cover a nickel five-cent 
piece before each feeding. 



808 ENTERITIS AND COLITIS IN CHILDHOOD. 

R. Pepsini purl, in lamellis, ,5j ; 

Villi pepsini, N. F., ^^ss; 

Aqu?e destillat., ^iiiss. Misce. 

Give half a teaspoonful to one teaspoonful, according to the age, before eacli feeding. 

If cerebral symptoms appear, as rolling the head, drowsiness, etc., indicat- 
ing the commencement of spurious hydrocephalus, an alcoholic stimulant, as 
whiskey or brandy, is required ; and although there may be, at times, great 
restlessness, explicit and positive directions should be given to withhold 
opiates if they have been previously employed. One of the bromides, with 
an alcoholic stimulant or the aniseed cordial of the National Formulary, to 
allay restlessness, would be the proper remedy in addition to bismuth and 
pepsin if symptoms of heart failure or spurious hydrocephalus occur. 

In protracted cases, when the vital powers begin to fail, as indicated by 
pallor, more or less emaciation, and loss of strength, the following tonic will 
sometimes be useful in restraining the diarrhoea and increasing the appetite 
and strength. It should not be prescribed until the diarrhoea has assumed a 
subacute or chronic character : 

R. Tinct. columbfe, f^iij ; 

Liq. ferri nitratis, TTLxxvij ; 
Syr. siraplic, .^j ; 

Aquse, Jij. Misce. 

Dose: One teaspoonful every three or four hours to an infant of one year. 

External Treatment. — In the gastro-intestinal catarrh of the cool months, 
produced by exposure to cold, light and mildly stimulating applications over 
the abdomen are sometimes useful, as a light poultice of flaxseed to which 
one-sixteenth or one-twentieth part of mustard is added, or a poultice of 
cloves, cinnamon, and ginger, or even camphorated oil, on the under surface 
of a flaxseed poultice, covered with oil-silk. But in those forms of gastro- 
intestinal catarrh due to improper feeding or insanitary conditions, and hav- 
ing a bacterial origin, external measures are commonly useless, and in the 
summer months they might do injury by increasing the warmth. 



CHAPTER IX. 

ENTERITIS AND COLITIS IN CHILDHOOD. 

Intestinal inflammation in childhood diff'ers materially from the form 
or type which it commonly presents in infancy. Its causes, symptoms, and 
extent vary in important particulars in the two periods. In childhood there 
is not ordinarily such extensive inflammation of the mucous membrane of 
the intestines as we have seen is present in the majority of cases in infancy, 
and it may therefore be properly treated as two diseases, according to the 
seat of the morbid process — to wit, enteritis and colitis. Both these afl"ec- 
tions in childhood resemble so closely the form which they exhibit in adult 
life that no extended description is needed in this connection. 

Causes. — A main cause is sudden reduction of temperature by exposure 
to cold or to currents of air, which checks perspiration and causes determina- 
tion of blood from the surface to the viscera. These inflammations are also 
caused sometimes by irritating substances in the intestines. I have known 



SY3IPT03IS— PROGNOSIS. 809 

fecal accumulations, as well as worms, to produce severe dysentery in the 
child, accompanied by the characteristic tenesmus and muco-sanguineous 
stools, and ceasing as soon as the offending substances were expelled. The 
use of unripe or stale vegetables, if there be a strong predisposition to 
mucous inflammation, may be a sufficient cause, and some of the most dan- 
gerous cases are due to the accumulation in the intestines of seeds and the 
parenchyma of fruits. But the most common cause is that mentioned — to 
wit, sudden exposure to cold when the body is heated, a danger to which 
children are especially liable on account of the easy disturbance of the cir- 
culatory system in them, and their heedless exposure of themselves unless 
incessantly watched. Enteritis and colitis are also frequently secondary dis- 
eases occurring in childhood as complications or sequelae of the eruptive 
fevers, especially measles. 

Symptoms. — The alvine discharges in enteritis and colitis in childhood are 
such as occur in these diseases at a more advanced age. In enteritis they 
are thin and of the natural color, or occasionally green ; in colitis they are 
more consistent than in enteritis and are largely muco-sanguineous. Some- 
times in enteritis, if the inflammation be not intense, the diarrhoea is slow in 
appearing, or it may be slight, so as not to attract special attention. The 
disease may then resemble remittent fever, for which it is at times mistaken. 
The upper part of the small intestines is less frequently affected than the 
lower. If there be duodenitis, the flow of bile is occasionally impeded from 
tumefaction of the mouth of the common bile-duct, and the icteric hue 
appears. In both enteritis and colitis there is abdominal tenderness, with 
more or less constant pain if the disease be severe, and in colitis tormina and 
tenesmus. The pulse is accelerated, the heat of surface augmented, the face 
flushed and, except in mild cases, expressive of pain. In many children at 
the commencement of the inflammation the nervous system is profoundly 
affected, as indicated by headache, stupor, twitching of the limbs, and some- 
times by convulsions. The chief danger at the commencement of the dis- 
ease is, indeed, from this source. Sometimes irritability of the stomach 
occurs and the food is rejected, though much less frequently than in the 
intestinal inflammation of infancy. Anorexia and thirst are common symp- 
toms. If the inflammation continue there is soon perceptible emaciation, 
with loss of strength. The eyes become hollow, the face pallid, and the 
surface cool. Death may occur at an early period, the vital powers succumb- 
ing from the intensity of the inflammation. In other cases the acute dis- 
ease ends in a subacute or chronic inflammation ; the patient becomes grad- 
ually more reduced, till he dies in a state of extreme emaciation, such as we 
often observe in the entero-colitis of infancy ; or from this state he may 
recover by degrees, though perhaps with an irritable state of the bowels, 
which continues for months. In a majority of cases, however, enteritis and 
colitis in childhood, if properly treated, soon begin to yield, and they termi- 
nate favorably in one or two weeks. 

Diagnosis. — It is not difficult to determine the existence of the inflam- 
mation. This is indicated by the fever, abdominal tenderness, and the relaxed 
state of the bowels. Whether the disease be enteritis or colitis is determined 
by the character of the stools, the seat of the tenderness, and the presence or 
absence of tenesmus. 

Prognosis. — It has been stated above that enteritis and colitis in chil- 
dren commonly terminate favorably. The result depends not only on the 
extent and severity of the inflammation, but the constitution and previous 
health. The inflammation is more serious when secondary than when pri- 
mary. Extensive and great tenderness of the abdomen, features pallid, anx- 
ious, and expressive of suffering, pulse frequent and feeble, should excite the 



810 ENTERITIS AND COLITIS IN CHILDHOOD. 

most serious apprehensions. Frequent vomiting also denotes a grave form 
of the disease. Stupor, and especially convulsive movements, show that the 
nervous centres are affected, and should make us guarded in the prognosis. 
Improvement in the disease on which to base a favorable prediction is appa- 
rent in the diminution of the tenderness, improvement in the pulse and 
character of the stools, a more cheerful countenance, and less disrelish of 
food. 

Treatment. — This should be similar to that employed for the adult. 
In enteritis at the commencement of the disease, if there be reason to sus- 
pect the presence of any irritating substance in the intestines, and ordi- 
narily in colitis, it is advisable to commence treatment by the use of some 
simple evacuant, like castor oil. After this our reliance, so far as internal 
treatment is concerned, must be mainly on opiates and antiphlogistic medi- 
cines. One of the best remedies of this class is the Dover's powder, which 
may be given to a child iSve 3'ears old in doses of three grains every three 
hours. A corresponding dose of any of the other opiates may be given, but 
with less sudorific effect. In colitis the occasional administration of a laxa- 
tive should not be neglected if the stools be entirely or mainly muco-sanguin- 
eous. It should be employed so as to prevent accumulation of fecal 
matters in the colon, which would serve as an irritant and increase the 
inflammation. The dose should be small, merely sufficient to produce fecal 
evacuation, and repeated as required, daily or less frequently. The laxatives 
commonly preferred are magnesia, rhubarb, or castor oil. The physician 
may prescribe an opiate mixture containing sufficient of the laxative to have 
the effect desired, though ordinarily it is better to prescribe the two sepa- 
rately, so that the laxative can be given or withheld according to circum- 
stances, while the opiate is continued more regularly. Except that there be 
some irritating substance which requires removal the effect of laxatives is 
injurious instead of beneficial. Instead of a laxative given by the mouth, 
the use of a clyster of glycerin and sweet oil in tepid water is often prefer- 
able. The following prescriptions may be employed for a child of five 
years : 

R. Pulv. opii, gr. v ; 

Bismuth, subnitrat., .5ij. Misce. 
Divid. in pulveres No. xx. Give one powder every two to four hours- 

R. Pulv. ipecac, comp., ,5j ; 

Bismuth, subnitrat.. 3ij. Misce. 

Divid. in pulveres No. xxiv. Give one powder as above. 

R. Tine, opii deodorat., .^ss ; 
Bismuth, subnitrat., ^ij ; 
Aq. menth. piperit., 
Syr. zingiberis, da. 5J. Misce, 

Shake bottle. Give one teaspoonful from two to four hours. 

The local treatment which is found most beneficial consists in the use of 
emollient applications covered with oil-silk, and made sufficiently irritating 
by mustard or otherwise to cause constant redness. 

The diet should be bland and unirritating. In the first stage of the 
inflammation rice or barley-water or arrowroot boiled in water and similar 
drinks should constitute the main diet. When the active inflammation has 
abated, and at any period of the disease if there be a tendency to pros- 
tration, more nourishing food should be given. Milk and animal broths may 
then be allowed. In cases which are protracted or attended with symptoms 
of exhaustion alcoholic stimulants are required. 



SYMPTOMATIC CONSTIPATION. 811 



CHAPTER X. 

COXSTIPATIOX. 

The gastro-intestinal portion of the digestive apparatus has a double 
function. First, it receives and retains the food during the process of diges- 
tion ; it furnishes the most important of the liquids b}' which digestion is 
effected ; and it absorbs those products of digestion which are required for the 
nutrition of the body, while it serves as a barrier against the admission of 
refuse matter. Secondl}^, it has an excretory function, so that a large part 
of the waste and noxious products of the system are eliminated from its 
surface. Having, therefore, a relation so close and fundamental to the gen- 
eral nutrition, it is necessary, for the normal activity of the organs and the 
maintenance of health, that its functions be regularly and fully performed. 
But retention of fecal matter beyond the normal period is one of the most 
common ailments both in infancy and childhood, and occasionally it consti- 
tutes a grave disease. The reader is referred to page 155 for remarks relating 
to constipation of the newly-born. 

Constipation is of two kinds — namely, symptomatic and idiopathic. 

Ssnnptomatic Constipation. — Causes. — ]Many of these are obstruc- 
tive. The more common of them are the following : (a) Congenital stenosis, 
or occlusion of the anus or rectum. The anus is not formed or it terminates 
in a cul-de-sac, while the lower end of the large intestine forms another 
cul-de-sac. These two cul-de-sacs, h'ing opposite to each other, one look- 
ing upward and the other downward, may be separated from each other by a 
small interspace, a fibrous septum, so that relief can be obtained by a punc- 
ture or incision, or they may be widely separated, so that there is no possible 
mode of relief, and death is inevitable unless the fecal matter escape through 
a congenital fistulous passage upon one of the adjacent mucous surfaces; 
which mode of relief was present in 40 per cent, of the cases of this 
obstruction collected by Leichtenstern. Exceptionally, this malformation 
occurs in the sigmoid flexure, while the rectum is normal. The stenosis, if 
slight, may produce little delay in the evacuations, except when hardened 
masses or coarse, indigestible substances descend upon it, and it may there- 
fore with careful selection of diet, cause little inconvenience for a length- 
ened period, while much stenosis causes early obstructive symptoms. 

Rarely the stenosis is at the ileo-cjecal orifice. (See page l55.) 

(h) Intestinal Di>iplacemenfs. — These produce obstructions of a very pain- 
ful and dangerous kind. Intussusception and external hernia are too well 
known to require description. Both are likely to produce complete obstruc- 
tion if not soon relieved, but there are cases of intussusception in children 
in which the displaced intestine remains pervious, and the evacuations occur 
with more or less regularity ; and the same is true of one form of hernia — 
namely, the congenital — which, although painful, seldom j^roduces serious 
obstruction. 

Painful and dangerous occlusion and consequent arrest of alvine evac- 
uations occasionally result from the imprisonment of a loop of intestine in an 
opening, usually congenital, in the mesentery or diaphragm, or from the 
knotting of one portion of intestine with another, as described by Leichten- 
stern, or again from the twisting of the intestine. Epstein and Soyka ^ relate 

1 Centralb. f. d. med. Wissensch., April 24, 1879. 



812 CONSTIPATION. 

the case of a new-born infant that died in the second week after birth with 
symptoms of obstruction. At the autopsy a portion of the small intestine 
with its mesentery was found twisted upon its axis from right to left, without 
any marked evidence of inflammation. 

(c) Substances which have been swallowed or substances whose nuclei 
have been swallowed, and which consist of a deposit of carbonate and phos- 
phate of lime, or substances which have been produced entirely in the sys- 
tem, and which, lodged in narrow parts of the intestine, cause obstruction. 
Such substances, some of which occur most frequently in children and others 
in elderly people, produce acute constipation. Indigestible matter contained 
in the food, as seeds or the parenchymatous portions of fruits, occasionally 
collects in considerable quantity and obstructs the intestine. A large gall- 
stone having escaped from the common bile-duct, sometimes lodges in the 
intestine, either at the ileo-c?ecal valve or more rarely at some other pointy 
and retards the passage of fecal matter. But this seldom occurs in children. 
In one instance, and in only one, have I known obstinate constipation to be 
produced by worms. The patient was a girl of about four years, in whom 
constipation came on suddenly, and was accompanied by distension of abdomen 
and great suffering. This continued nearly one week, when a mass of 
intertwined round worms was expelled, with immediate relief. The records 
of medicine also contain cases in which neoplasms, growing from the coats 
of the intestines internally, have attained such a size as to retard the evac- 
uations. 

((f) Abscesses and tumors, especially when occurring in the pelvis, also 
sometimes cause constipation by pressing upon the intestine and obstructing 
or narrowing the passage through it. Thus, in 1868, Mr. Thomas Smith 
related to the London Pathological Society the case of an infant, aged four- 
teen months, in whom both alvine and urinary evacuations were retarded by 
a cancerous tumor growing between the rectum and bladder, and ending fatally 
in three months after the occurrence of the first symptoms. 

(e) Peritonitis, during its continuance, is known to constipate the bowels. 
It is supposed that inflammatory oedema occurs around the muscular fibres 
of the middle coat, by which their contractility is impaired. Hence the lax 
state, the meteorism, and inaction of the intestines in this disease. When 
the peritonitis abates the normal action is restored and the evacuations occur 
regularly if the free surface of the peritoneum have undergone no unfavor- 
able change. But, unfortunately, peritonitis often produces more lasting 
injury, so as to interfere seriously with the intestinal movements and produce 
an habitually torpid state of the bowels. This occurs from adventitious 
bands of inflammatory origin which lie across the intestines, compressing- 
them at the points of contact and restraining their movements, and from 
adhesion of the intestinal loops. 

The most marked cases which I have observed of this were children who 
had had tubercular peritonitis. The following was an interesting example : 

Case. — Charles, aged four years, was returned to the New York Foundling 
Asylum on April 16, 1877, to be treated for tumor albus of the left knee and for 
general ill-health. His parentage and early history were unknown. The nurse 
in the city to whom he had been entrusted when quite small stated that he had 
no sickness when with her except sore eyes, and that about April 1, 1877, the 
enlargement of the knee was first observed. The head of the boy was large and 
the abdomen much distended, but without any decided tenderness on pressure ; 
its entire lower part had a purplish color. Percussion over it gave a dull sound, 
except upon and near the epigastrium, where there was some resonance ; umbili- 
cus prominent; circumference of body over abdomen, twenty-three inches ; pulse 
128 ; axillary temperature 99°. It was stated that he had no stool without medi- 
cine, and that usually one tablespoonful of castor oil was required to produce it. 



IDIOPATHIC CONSTIPATION. 813 

The urine contained no albumen and was apparently normal. As the appearance 
indicated struma, a mixture of cod-liver oil, syrup of the lactophosphate of lime, 
and iron was prescribed, to be given three times daily, and directions were given 
to rub cod-liver oil over the abdomen also three times each day for five minutes 
each time. Some nodules were felt on pressure upon the abdomen, which we 
suspected were enlarged mesenteric glands. From the day on which the friction 
and kneading of the abdomen were commenced the stools began to occur, on the 
average, about twice daily. The kneading proved the safest, as well as most 
efficient, method of producing defecation. 

On May 4th the circumference of the trunk over the most prominent part of 
the abdomen was reduced to twenty-two inches. The records on May 11th state: 
''Same treatment is Continued ; has tolerable appetite, but is pallid, and his flesh 
flabby and soft." On May 22d the circumference of the trunk gave twenty-two 
and three-quarter inches. The tumor albus remained about the same. 

I saw the patient again during attendance in the asylum in August and 
November. The record in November states that he is feeble and failing ; is 
becoming weaker and thinner ; breath and exhalations from the surface offen- 
sive ; he is kept quiet on account of the knee. From this time he gradually 
failed, and died April 11, 1878. There was no cough to attract attention, and 
instead of constipation a diarrhoea of some weeks' continuance preceded death. 

Autopsy. — Lungs healthy, except a little exudation over the summit of right 
lung ; bronchial glands cheesy ; numerous tubercles, some of them cheesy, upon 
the parietal and visceral surface of the peritoneum. Loops of the intestines were 
united to each other by old adhesions, and the small intestines were generally 
bound down by bands into a " uniform conglomeration ;" mesenteric glands 
enlarged and cheesy ; a large ulcer upon the surface of the rectum, and numer- 
ous small round ulcers upon the surface of small and large intestines, apparently 
occupying the site of the solitary follicles. 

Occasionally a false band, the result of peritonitis, lies across the intes- 
tines, without restraining their movements, and producing no marked symp- 
toms, and probably no symptoms at all, until a loop happens to pass under- 
neath it, when, if not soon released, it is liable to become strangulated, with 
complete obstruction to the passage of fecal matter. This displacement might 
properly be classified with the internal hernias described above. Li my own 
person at the age of twelve years such an accident occurred about two months 
after the peritonitis. Upon the abatement of the inflammation a sensation 
of traction had been noticed in the umbilical region almost daily during exer- 
cise, and the displacement was indicated by the extreme pain which character- 
izes such cases, and which ceased suddenly when the parts were released 
after about eighteen hours. 

(/) "^Vhile it is important that the diet and glandular secretions should 
be such that the feculent matter may have proper consistence for easy pro- 
pulsion along the intestinal tube, the important agent by which alvine evacua- 
tions are eff'ected is obviously muscular contraction. The muscular fibres of 
the intestines produce the vermicular and peristaltic movements by which the 
excrement is carried forw^ard, and the abdominal muscles by their powerful 
contraction are the chief agents of expulsion. Now, any pathological state 
which impairs the innervation of these muscles or renders it abnormal, 
destroying the proper balance between " exciting and inhibiting impulses," 
is likely to cause constipation. Hence meningitis, myelitis, and certain other 
diseases of the cerebro-spinal axis, rachitis, general weakness, etc., are com- 
monly attended by a sluggish state of the intestines, either from tonic 
contraction of the muscular fibres of the middle coat, as in meningitis or 
from paral3^sis. 

Idiopathic Constipation. — Causes. — These are quite numerous. The 
more prominent of them are the following : First, too little liquid in the 
excrement, so that it is too firm for ready evacuation. There may be too 
little liquid taken in the ingesta or too scanty secretion of the liquids which 



814 CONSTIPATION. 

mix with the food, as those of the pancreas, liver, and mucous follicles, or 
there may be too great an absorption of liquid through the coats of the 
intestines, and too active an excretion of water from the skin, kidneys, or 
lung. The firmer the fecal matter the greater the tendency to constipation. 
Those who lose a large amount of water, as in diabetes, night sweats, or from 
occupations which expose to heat or from residence in a hot climate, are espe- 
cially liable to constipation, except as the loss of liquid is compensated by an 
increased amount of drink. 

The character of the food, apart from the amount of liquid which it con- 
tains, obviously has a marked influence upon the consistence and frequency 
of the stools. Occasionally, the intestines act sluggishly from insufficiency 
of food. Thus, the infant sometimes hangs an unusually long time on the 
breast, and the mother or wet-nurse believes it to be a hearty nurser, when 
there is really a deficiency of milk, and the stools are scanty and infrequent 
from lack of material. Again, constipation is not uncommon in infants who 
nurse heartily and seem to obtain a sufficient quantity of milk, and the cause 
of it is not in the state of the digestive organs, but in the milk. AVe find 
that now and then breast-milk has a constipating eff"ect, although we discover 
nothing to cause this result in the mother's diet or health. The comparison 
of ordinary milk with colostrum may furnish a clew to the explanation. 
Colostrum is known to be more laxative than ordinary milk, and it differs 
from it chemically in containing more butter, sugar, and salts. Hence the 
theory seems plausible that when breast-milk is constipating these elements 
occur in less than the normal quantity. And we shall see hereafter that treat- 
ment suggested by this theory obviates the constipation. 

The use of a diet which consists chiefly of assimilable substances, as ani- 
mal food, and from which, after the digestive process, little coarse and stimu- 
lating residuum remains, is obviously liable to produce a sluggish state of the 
bowels. ■ On the other hand, coarse food, as fruits with their seeds, coarsely- 
ground meal, etc., which stimulates the peristaltic action and the secretions, 
increases the number and frequency of the alvine discharges. 

Habit also exerts a decided influence upon defecation. One who, for 
whatever reason, neglects or resists the desire for a stool soon becomes less 
conscious of the daily recurring need and establishes a constipated habit. 
Constipation is more liable to occur in those who lead a quiet life than in 
those who are active. A constipated habit is established in many school- 
children by neglecting or repressing the desire for a stool during school hours. 

But there are cases in which there seems to be a constitutional tendency 
to constipation — a tendency quite independent of the usual conditions. Thus 
I have met children who were bright and active, free from obstruction or 
disease which might retard the evacuations, apparently far from having 
sluggish muscular contractility, and, so far as I could see, with proper diet, 
and yet with defecation, except as it was produced by measures employed, 
occurring no oftener than each second, third, or fourth day. 

But it must be borne in mind that what is constipation in one child may 
not be in another, for occasionally one does well with only one evacuation 
every second or third day, while a large majority require daily defecation in 
order to the maintenance of perfect health. 

In the adult the sacculi or pouches which occur in the walls of the colon, 
produced by contraction of the longitudinal bands acting at right angles to 
the direction of the circular fibres, and consisting of the internal and exter- 
nal tunics without the muscular, become the receptacles for fecal matter in 
those who are constipated, and obviously tend to increase the constipation. 
In children these sacculi are much less developed relatively, and in young 
infants, whose intestines lack the longitudinal bands, are absent, so that this 



SYMPTOMS. 815 

anatomical condition by which the passage of fecal matter is delayed, is 
unimportant as a cause of constipation in the young. 

On page 157 we have stated that Gautier of Geneva, Switzerland, has 
called attention to an anal fissure as a cause of constipation in the newly- 
born and in older children. The constipation occurs from the endeavor to 
resist defecation on account of the pain. 

We have also remarked on page 157 that constipation has a tendency to 
perpetuate itself, since retained feculent matter becomes more consistent and 
firmer, and the contractile power of the muscular tunic becomes weakened 
by long distension. Obviously, also, an abnormal length of the large intes- 
tine, so that it doubles on itself, whether congenital or the result of con- 
stipation, and a malposition which diminishes the space occupied by the colon, 
and therefore increases its flexures, have a tendency to produce constipation. 

Symptoms. — When there is a mechanical cause which retards the pas- 
sage of fecal matter the acuteness of symptoms and the suffering are gen- 
erally proportionate to the degree of obstruction. Symptomatic constipa- 
tion occurring in an obstructive disease, whether adhesions, peritoneal bands, 
intussusception, knots or twisting of the intestine, incarceration in a false 
passage, or from biliary or intestinal stones or fecal masses, is attended by 
severe symptoms, such as intense colicky pain, vomiting, loss of appetite, 
and rapid prostration. The ingesta accumulate above the point of obstruc- 
tion, producing distension of the intestine with fecal matter and gas, while 
below the point of obstruction the intestine is soon empty. The symptoms 
indeed have the severity and the state involves the danger present in ordinary 
strangulated hernia, while, from being internal, and therefore less accessible 
for treatment, the danger is even greater. If the intestinal tract be narrowed, 
whether by a false ligament, the result of an old peritonitis, or other cause, 
and there be still perviousness, so that excrementitious matter passes by the 
obstruction, though slowly and with more or less difl&culty, the patient may 
be comparatively comfortable if the food be such that no hard masses 
remain ; but according to the degree of stenosis and the amount and coarse- 
ness of the fecal matter symptoms occur referable to the obstruction. If the 
excrement be propelled with difficulty through the narrowed part, the mus- 
cular coat above the obstruction gradually becomes more developed from 
hypertrophy of the muscular fibres, just as the heart enlarges from obstruc- 
tive disease of its valves, while below the obstruction the intestine atrophies 
and its calibre diminishes from disuse. Colicky pains, accumulation of fecal 
matter above the obstruction, distension of abdomen, eructation of gas, vom- 
iting, impaired appetite, and consequent decline of the general health are 
common results. There is constant danger in these cases that the narrow 
passage may become obstructed by fecal matter if it happen to contain hard 
masses or coarse indigestible substances. The gravest form of constipation 
is obviously that due to mechanical agencies which act as obstacles, but as 
the obstacles are numerous, differently located, and of different character, so 
there is great difference in the gravity of the cases. 

Idiopathic constipation generally comes on gradually. It at first attracts 
little attention and is neglected. The symptoms of course vary greatly 
according to the degree and stage of constipation. In mild cases the reten- 
tion is only in the rectum or rectum and sigmoid flexure, and there are no 
marked symptoms except a sensation of fulness or distension of these parts, 
which one or two evacuations relieve. Between these mild cases and the 
graver forms of constipation there is every intermediate grade, attended by 
symptoms proportionately severe. It is surprising sometimes to observe how 
long patients live with extreme constipation, though with constant suffering 
and ill-health ; and — which I wish especially to be noticed in this connection 



8 1 6 CONSTIPA TION. 

— a large proportion of the fatal cases of idiopathic constipation occurring in 
adults and recorded in the literature of the profession began in early life, 
even in infancy, at which time they probably might have been relieved by 
proper remedies and a life of suffering prevented. This important practical 
fact shows the need of greater attention on the part of parents and nurses to 
the state of the bowels in children, that their sluggish action may be cor- 
rected before it becomes habitual and those anatomical changes of distension 
and muscular paralysis occur which are with difficulty corrected. 

A case quite remarkable and of recent date occurred in the practice of Dr. 
Strong^ of Westfield, N. Y. : 

Case. — This patient at the age of two years usually had one stool in two 
weeks, and several years later only one in six weeks. When an adult he was 
treated by Dr. Strong, who found great distension of the abdomen, so that the 
lower ribs were pressed outward in nearly a horizontal direction, and the tho- 
racic organs upward, so that the apex-beat of the heart was about one inch 
above the nipple. At this time months elapsed between the stools, the longest 
intervals being eighteen months and sixteen days. Defecation when it did occur 
lasted from two to four days, and was attended by violent gastric and intestinal 
pain, vomiting, and prostration. At one of these prolonged stools forty pounds 
of feces, resembling, as it usually did, chewed brown paper, were evacuated, the 
quantity being accurately ascertained by weighing the patient before and after- 
ward. He had appetite and was able to do certain kinds of farm-work during 
the year preceding his death, which occurred at the age of twenty-eight years. 
At tiie autopsy the colon was found to have a length of six feet and three inches 
and a circumference of thirteen inches, while the lungs were pressed upward and 
backward as when compressed by a pleuritic exudation. 

While such extreme cases are infrequent, all physicians of experience are 
consulted from time to time by adults who have had habitual constipation 
from their earliest recollection ; and these cases, that aggregate so large a 
number, might, there is little reason to doubt, have been prevented for the 
most part during childhood when the habit was being formed. 

In long-continued constipation, in which there is a large fecal accumula- 
tion, not only is the diameter of the colon increased, as stated above, but this 
part of the intestine becomes elongated. This may lead to change in its 
position, the curves of the sigmoid flexure extending farther to the right, and 
the central part of the transverse colon by its weight curving downward. 
This abnormal lengthening and the consequent curvatures have a tendency 
to increase the constipation, as has been stated above in our remarks relating 
to the etiology. 

In these cases of extreme constipation, which fortunately are rare in chil- 
dren, as they are also in adults, the distension of the colon at the ileo-caecal 
orifice has a tendency to widen this orifice, so that the valve, which in the 
ordinary state prevents the return of any substance which has once passed 
by it, is liable to become insufficient. The adjacent folds which constitute 
the valve become separated, so that, if vomiting and antiperistaltic move- 
ments occur, fecal matter may pass from the colon toward the stomach. In 
aggravated cases, in which there is retention of a large amount of fecal mat- 
ter, distension, muscular paralysis, etc., similar to those which we have seen 
produced in the colon, are liable to occur, though to a less extent, in the 
small intestines, especially in the ileum. 

Retained excrementitious matter accumulating in large masses evidently 
becomes an irritant, so that by its pressure it excites muscular contractions, 
which if ineffectual in propelling the mass cause colicky pains. The retained 
fecal matter also undergoes more or less decomposition, producing gases which 
by increasing the distension also increase the pain. 

1 Amer. Jour, of Med. Sci., 1874 and 1876. 



TREATMEXT. 817 

Any irritating substance applied to a mucous surface is liable to excite 
increased secretion from tlie mucous follicles or from the glands whose ori- 
fices connect with the mucous membrane at the point of irritation. Many 
familiar examples will at once be recalled to mind, as the defluxion from the 
nostrils from the use of snuffs and increased mucous secretion and salivation 
from objects held in the mouth. In the same way, retained excrement, form- 
ing hard masses which press upon the intestinal surface, excite a secretion, 
and not infrequently produce thereby a diarrhoea which is conservative, and 
which may for the time unload the bowels, or it may remove a part of the 
scybalae, while the rest remain. Hence we sometimes hear patients speak of 
having irregular evacuations, constipation alternating with diarrhoea. In 
aggravated cases the pressure of impacted feces sometimes produces inflam- 
mation of the surface, when, in addition to abdominal pain, there are tender- 
ness on pressure and some (usually quite moderate) elevation of tempera- 
ture. In cases which have terminated fatally after a longer or shorter 
time, destruction of the mucous surface has been found in places in conse- 
quence of the pressure and inflammation. We can readily believe that, as 
in cases of typhoid ulcerations, if the ulcers reach a certain depth they may 
also give rise to localized peritonitis, and that occasionally perforation may 
result at the ulcerated or gangrenous point. The expulsion of hardened 
masses which have collected in the rectum is slow and painful, and accom- 
panied by more or less tenesmus, which not infrequently causes a portion of 
the mucous membrane at the anal orifice to descend below the sphincter ani 
and protrude, by which hemorrhoids are produced. Occasionally, as I have 
observed in certain cases, the entire circumference of the rectal mucous mem- 
brane, to the distance of half an inch or more above the anus, becomes so 
loosened from its attachment to the connective tissue that it descends below 
the sphincter ani and protrudes during each defecation. But this displace- 
ment, known as prolapsus recti, more commonly results in children from pro- 
tracted intestinal catarrh, attended b}^ diarrhoea, loss of flesh, and by dimin- 
ished tonicity of the tissues. 

A beautiful and conservative provision in the system is that by which 
vicarious functions are established to relieve organs which imperfectly per- 
form their part. While the intestinal surface is to a great degree elimina- 
tive, so that noxious and efiete products are largely expelled from the system 
in the stools, it possesses also in high degree an absorbent function, as all 
who employ rectal alimentation are aware. Now, if the intestine fail to per- 
form its function of defecation and feculent matter collect within it and 
begin to exert pressure upon the intestinal surface, more or less of the liquid 
portion is taken up by the vessels, and, entering the general circulation, finds 
a mode of escape through other emunctories. The general ill-health or 
languor, the furred tongue, headache, and foul breath which characterize these 
cases are, no doubt, due to the absorption into the blood or retention in it of 
noxious products contained in, and which in part constitute, the feculent 
matter. The fact that patients may live for years with tolerable appetite, 
and with only one dejection every second or third week, receives explanation 
in the fact that other organs, as the lungs, kidneys, skin, etc., act as depur- 
ants for such excrementitious matter as can be taken up in a liquid or gas- 
eous form by the intestinal surface. 

In infants, constipation, even when slight and temporary, often causes fret- 
fulness, which is indicated by the character of their cries and the movement 
of the thighs over the abdomen. Continuing for a time, it causes more or 
less fever, and in those young children who are liable to eclampsia it predis- 
poses to an attack, and it may be the chief cause. 

Treatment. — If there be reason to suspect the presence of a mechanical 



818 CONSTIPATION. 

obstacle which prevents normal defecation, a careful examination should be 
made in order to discover, if possible, its nature and location. Often it is 
of such a nature that it cannot be removed, but its constipating effects may 
sometimes be in a measure obviated. In one of the published cases in which 
constipation continued from early childhood to adult life, and finally proved 
fatal, its cause was ascertained to be a septum in the rectum, which probably 
might have been relieved by surgical measures. In all cases of constipation 
which the history shows may be produced by mechanical causes, whether the 
obstruction be complete and the colicky pains and other symptoms severe, or 
there be occasional scanty evacuations with but slight or moderate suffering, 
the history of the patient should be obtained in order to ascertain if there 
had been at any previous time symptoms of peritonitis or other pathological 
state which might throw light on the etiology. The abdomen and the usual 
sites of hernia should be carefully explored by palpation, and the rectum by 
the finger, large-sized catheter, or rectal tube. A thorough examination thus 
instituted, painless to the patient, will usually enable the practitioner to deter- 
mine either the exact or probable obstacle if any be present. 

The proper treatment of symptomatic constipation obviously requires the 
removal, so far as possible, of the primary disease or the cause, whether it be 
obstructive or otherwise. We need not stop to consider the special meas- 
ures which are required, and will pass to the consideration of the treatment 
of idiopathic constipation. 

Hygienic Measures. — We have already alluded to the fact that habit has a 
powerful control over the action of the intestines, so that it is important to 
obtain a daily alvine evacuation at a certain hour, and by establishing the 
habit the need will usually be experienced when that hour arrives each day. 
Many cases which become troublesome and obstinate might no doubt have 
been prevented had this physiological law been heeded and a daily evacuation 
obtained at a certain hour. The constipated habit, mild and not yet fully 
established, is more liable to be overlooked when it occurs in childhood than 
in infancy, for the infant is closely and constantly under observation, and it 
soon presents symptoms, as fever and fretfulness, if it do not have the regu- 
lar evacuation, while children over the age of four or five years tolerate better 
a sluggish state of the bowels, and are likely to be constipated for a consider- 
able time before it is ascertained. They therefore require more attention in 
this regard than is usually bestowed by parents. 

The nature of the diet is obviously important, as certain kinds of food 
are more laxative than others. Chicken tea and, to a certain extent, beef 
and mutton tea, are laxative, and made plainly are therefore useful in con- 
nection with other articles. The various kinds of berries and fruits have 
also a decidedly stimulating effect on the intestinal surface and aid in remov- 
ing constipation. The apple scraped or baked, or apple sauce, may be given 
to quite young children ; and for those that are older currants, cherries, and, 
among dry fruits, prunes and figs, are laxative. Unfermented cider in its 
season, which has been found so useful for adults, may also be given to 
children in moderate quantity, at least to those who have reached the age 
of two or three years. 

By the digestive process starch, which is unassimilable, is changed into 
grape-sugar, which can be absorbed and assimilated, and from the small size 
of the salivary glands in the first months of infancy it is believed that the 
salivary and pancreatic fluids are insufficient to convert starch into grape- 
sugar except in very inadequate quantity. It appears, however, highly prob- 
able that there is an epithelial ferment which converts starch into sugar,^ so 

^ " Chemical Phenomena of Digestion," by Charles Ricliet, Rev. des Sci. mid., Oct., 
1878. 



TREATMENT. 819 

tliat young infants can digest starchy food in limited quantity. The belief 
that the infantile digestion up to a certain age is inadequate to effect the 
change led to the preparation of food for infants in which the change of starch 
into grape-sugar was accomplished by a chemical process. Now, grape-sugar, 
given in considerable quantity, is laxative, and I have found it necessary to give 
it sparingly and with other food in the hot months, when infants are prone to 
diarrhoea. But this; laxative effect renders the glucose preparations of the 
shops very useful in the treatment of habitual constipation of infants, whether 
we employ the " maltose " or " granulated sugar of malt " or the preparations 
of Liebig's food. Of four constipated infants in the New York Infant Asy- 
lum to whom Horlick's " sugar of malt " was given, three were relieved. 
Any of the glucose preparations can be given quite freely to a constipated 
infant without impairing the digestive function or producing other ill-effect, 
so long as no more than the normal evacuations are produced ; and I consider 
them among the best and safest of the foods for the relief of constipation in 
infants ; but glucose or grape-sugar is only feebly laxative, probably not 
more than cane-sugar. 

Oatmeal is more laxative than most other kinds of amylaceous food. 
Made into a gruel and strained, it may be given to the nursing infant, and 
unstrained to those who are older. Bread or pudding from coarsely-ground 
or unbolted flour or meal, and vegetables which contain saline and fibrous 
substances, have a stimulating and laxative effect on the surface of the intes- 
tines, and therefore are useful for constipated children of the age of two or 
three years and upward. 

There can be no doubt that the free use of water in the ingesta materially 
aids in relieving costiveness. In one of the numbers of the London Lancet 
a physician asks the profession how to cure obstinate constipation in adults. 
Among the replies, one physician suggests drinking a tumblerful of cold 
water on retiring to bed and another tumblerful in the morning ; and there can, 
I think, be little doubt that the laxative effect of broths, gruels, fruits, and 
mineral waters is partly due to the amount of water which they contain. 
One of the chief causes of constipation, we have seen, is too great firmness 
or consistence of the stools, due to absorption of the water ; and if a larger 
quantity of water be swallowed during or after the meals than is removed by 
absorption, so that the stools have their normal or less than normal consist- 
ence, this cause of constipation is removed. An excess of water introduced 
into the system is to a great extent eliminated by the kidneys, and in hot 
weather by the skin, and to a certain extent exhaled from the lungs ; but 
experience shows that if the amount of liquid received be so great that the 
vessels in the coats of the intestines continue in a state of repletion, only a 
certain part of it is absorbed, while the rest descends and mixes with the 
excrementitious matter. 

The simple expedient of allowing a liberal use of water, so useful in 
adult cases, doubtless also has a laxative effect in children, and its judicious 
use is proper for them. Another important aid in overcoming habitual con- 
stipation is frequent kneading of the abdomen. My attention was first par- 
ticularly directed to this in the treatment of the case related above, in which 
obstinate constipation, occurring in a child of three years from peritoneal 
bands and adhesions, was to a great extent corrected by friction over the 
abdomen for three or four minutes at a time, with cod-liver oil three or four 
times daily. The manipulation probably did the good, and not the oil, but 
the use of one of the oils for inunction renders the kneading less painful 
and ensures its more thorough performance by the nurse. All obstetricians 
in certain emergencies stimulate the uterine muscular fibres to contraction by 
kneading the abdomen, and it is probable that the muscular fibres of the 



8 20 CONSTIPA TION. 

intestines are stimulated in a similar manner, so that the intestinal move- 
ments are increased by which feculent matter is carried forward. 

The external application of cold, so effectual in contracting the uterine 
muscular fibres, also stimulates the contractile power of the muscular fibres 
of the intestines. Cold-water bathing, the sudden application of a cloth 
wrung out of cold water to the abdomen, and in certain obstinate cases even 
the douche, may be used to stimulate the muscular coat of the intestines and 
the abdominal muscles to greater activity. Trousseau says: " Before leaving 
the subject of the treatment of constipation, let me refer to the application 
of cold to the abdomen — a minor method which I have seen recommended, 
and have myself prescribed with astonishing success. On rising in the morn- 
ing let there be placed on the abdomen a compress of several folds soaked in 
cold water, and let it be separated from the clothes by a sheet of gutta-percha 
or caoutchouc. This compress ought to remain on for three or four hours." 
This recommendation by Trousseau is for adults, who are much less suscept- 
ible to the influence of cold than children. So prolonged an application of 
cold and wet to a child, even the most robust, would involve danger, while its 
application during the brief period occupied in an ordinary bath, with proper 
exercise afterward or with other measures to prevent chilling, could have no 
ill-effect. 

Therapeutic Meamres. — For temporary constipation and many cases that 
are habitual enemata should be employed, since they promptly unload that 
part of the intestines in which feculent matter is ordinarily retained, while 
they do not impair the appetite or produce the prostration which so often 
results from purgatives. For temporary constipation a warm clyster may be 
given, and it commonly is more agreeable to the patient than one of lower 
temperature than the body. Among the enemata which have been found 
useful are castile soap with molasses and water, salt and water, the various 
oils, as sweet oil with or without castor oil, linseed oil alone or with molasses, 
and the gruels, as that of oatmeal or cornmeal made thin. The belief that 
the frequent use of warm clysters produces a relaxing effect is probably cor- 
rect, so that if it be necessary to employ clysters often in consequence of the 
torpid state of the intestines, cool water, the effect of which is tonic and stim- 
ulating, should be used. I prefer the use of glycerin and water as a laxative 
enema. For ordinary constipation in an infant the injection into the rectum 
of one teaspoonful of glycerin and one teaspoonful of water from a gutta- 
percha or glass syringe, at a certain hour each day, will rarely fail to give 
relief. 

For infants, a clyster of one or two ounces usually suffices, administered 
by a gutta-percha or glass syringe, while for older patients a proportionately 
larger quantity is required, administered by preference through a Davidson, 
India-rubber, or a fountain syringe. In certain long-continued, aggravated 
cases the frequent injection of a large quantity of tepid water is indispensa- 
ble in order to wash away the accumulation of fecal matter. Thus in 1854, 
Mr. Gay exhibited to the London Pathological Society a boy of seven years 
who at the age of three years had had typhus fever with dysenteric stools. 
After convalescence he had habitual obstinate constipation, so that when Mr. 
Gay began treatment there had been no fecal evacuation for nearly four 
months, and the girth of the body over the abdomen was forty-nine inches, 
and yet the appetite and general health were not seriously impaired. The 
shape of the abdomen and the examination showed great distension of the 
rectal ampulla and the descending colon. Mr. Gay first distended the 
sphincter ani, so that it admitted a speculum, and through a rectal tube, well 
introduced into the colon, the excrement was repeatedly washed away, so that 
at the time of the exhibition of the boy to the society the measurement in 



TREATMENT. 821 

girth gave only twenty-four inches. Evidently in cases like the above no 
other treatment except repeatedly washing out the intestines with warm water 
would have answered, and the dilatation of the sphincter ani and the 
introduction of the speculum to facilitate the escape of fecal matter are 
noteworthy. 

Suppositories may sometimes be usefully employed in place of enemata ; 
cocoanut butter, molasses candy, or soap cut in shape of a pencil may be 
used for this purpose. In the adult, long-continued constipation is not very 
rare in which the rectal ampulla becomes so impacted that it is necessary to 
use the anal curette, the handle of a spoon, or the finger introduced, in order 
to break up the masses and allow them to pass. In children necessity for 
such treatment is much more rare, but there are occasional cases, like that 
above described by Mr. Gay, in which it may be needed. Dr. Nagel states 
that the evil may be removed by the introduction of a suppository of brown 
gelatin. This is steeped in water for twelve hours, and, having been thus 
softened, is introduced into the rectum and an evacuation obtained. The 
doctor attributes the laxative effect to the hygrometric action of the gelatin. 
The glycerin suppository of the shops is also very effectual. 

The known effect of the galvanic current in producing contraction of the 
uterine muscular fibres suggests its employment to relieve constipation by 
stimulating the muscles of the abdomen and the muscular coats of the intes- 
tines ; and those who have employed it speak favorably of its use. Habershon 
says : '' A galvanic current, transmitted through the abdominal walls, induces 

a very speedy action, or rather emptying, of the colon A case of 

partial paraplegia, in which injections did not act satisfactorily and drastic 
purgatives were undesirable, was treated by a galvanic current passed through 
the abdomen every morning. In a few hours a free evacuation was produced 
without any discomfort." But the constipation of children very seldom 
requires the use of galvanism. 

The ordinary purgatives should not be given habitually to relieve a con- 
stipated habit. They are liable to irritate the intestines, causing a catarrh, 
or else the intestines become accustomed to their action and a larger dose is 
needed to effect purgation. Given habitually, they cannot fail also to disturb 
the digestive and nutritive processes. One or two doses for present relief, 
both in habitual and temporary constipation, is sometimes required, provided 
that an injection is for any reason not preferred. For this purpose, castor 
oil or a few grains of calomel mixed with syrup of rhubarb, the syrup of 
senna, or the compound liquorice-powder of the German Pharmacopoeia may 
be administered with advantage. But for habitual constipation I strongly 
advise to discard the ordinary purgative medicines, and if the measures of 
a dietetic or hygienic character recommended above are not sufiicient, to 
employ such remedial agents as promote, or at least do not impair, nutrition. 
Probably the best purgative for habitual use is maltine with fluid extract of 
cascara sagrada. 

Belladonna, so highly recommended by Trousseau and others, I have often 
administered to children, especially in pertussis, in large doses during several 
consecutive days, but it has not seemed to me to have any decided laxative 
effect. Though it may be useful in certain mixtures for adults, our experi- 
ences in this country with reliable preparations certainly have not been such 
as to justify its employment as the sole or main remedy for constipation. It 
diminishes reflex irritability, and may render the action of purgatives less 
painful, but from its known physiological effects we cannot believe that it 
increases the intestinal secretions or the action of the muscular fibres, one or 
the other of which results we expect from the use of an agent which is really 
laxative. On the other hand, nux vomica and its active principle, strychnia, 



822 INTESTINAL WORMS. 

are doubtless valuable adjuncts to purgative mixtures from their effect in 
increasing the action of muscular fibres. 

Physicians are not infrequently at a loss what to prescribe for the habitual 
constipation of nursing infants, which is by no means infrequent. But 
recollecting that colostrum is more laxative than ordinary milk, and that it 
differs from it in containing more sugar, salts (largely phosphates), and butter, 
we have a hint, as stated above, as to what is prol3ably lacking in the milk, 
and what, therefore, should be supplied. 1 am in the habit of giving the oil, 
sugar, and salts in the following formula, and usually with the desired laxa- 
tive effect : 

R. 01. morrhuje, 2 parts. 

Aq. calcis, 

Syr. calcis lactophos., da. 1 part. 

One-quarter, one-third, or one-half teaspoonful may be given with each 
nursing, or a larger quantity, as a teaspoonful or more, three times daily. 
Breast-milk with this addition becomes more nearly like colostrum in its 
laxative properties, while it does not possess those properties of colostrum 
which disturb the digestive process. I know no agent of a medicinal nature 
which meets the indication so well as this for infantile constipation. But in 
my practice I have found it necessary, in not a few instances, to rely mainly 
on enemata of glycerin and water for the relief of the constipated habit till 
the infants reached the age when a mixed diet was proper. 

The habitual constipation of older children may ordinarily be relieved by 
the remedies recommended above, but occasionally a more active purgative 
effect may be needed. Since the portion of intestine which is chiefly impli- 
cated in ordinary forms of constipation is the colon, it is evident that if it be 
necessary to employ frequently any of the active purgatives of the Phar- 
macopoeia, such should be selected as produce little or no irritation of the long 
tract of the small intestines, while they stimulate the function of the colon. 
The aloetic preparations are used for this purpose, as the tincture of aloes 
and myrrh or the simple tincture of aloes, which may be given in dose of 
part of a teaspoonful in a convenient syrup or in coffee or milk. But I think 
a preferable remedy is maltine with fluid extract of cascara sagrada, as 
recommended above, a half teaspoonful of which may be given daily, if 
necessary, to a child of eight years. 



CHAPTER XI. 

INTESTINAL WORMS. 

The belief has been prevalent in the profession in former times, and is 
now among the people, that worms in the intestines constitute a frequent 
disease, especially in children. As pathology and the means of diagnosticat- 
ing diseases are better understood, this idea has been gradually abandoned 
by physicians and the intelligent portion of the community. Still, these 
parasites must be considered an occasional cause of serious derangements, 
and in rare instances a cause even of death. They indeed often exist in 
small numbers without producing any appreciable deviation in the individual 
from the healthy state; but the most common and best-known species, when 
they have once "effected a lodgment in the intestines of man, ordinarily grow 



INTESTINAL WORMS. 823 

and multiply so as to produce symptoms and require medicines for tbeir 
expulsion. 

So far as is now ascertained by observations in different countries, about 
fifty animal parasites make their abode in man. It is not improbable that 
the number will yet be found greater by observations in distant uncivilized 
countries. Of these fifty, twenty-one reside in the alimentary canal (Heller), 
several of them being microscopic. Of those occupying the intestines only, 
the following species are specially interesting to the practising physician on 
account of their relation — for the most part causative — to certain path- 
ological states : to wit, the ascaris lumbricoides, or round-worm ; the 
oxyuris vermicularis, or thread-worm; the bothriocephalus latus ; and 
three species of taenia, or the tape-worm, and the trichocephalus dispar, or 
whip- worm. 

Ascaris Ljimhricoides. — The round-worm has a dingy reddish or yellowish- 
red color and a cylindrical form, tapering toward both extremities from the 
point of its greatest diameter, which is a little posterior to the middle. The 
dead worm is paler than the living. The anterior extremity is tipped with 
three tips, between which and the body is a circular groove. Between these 
three tips anteriorly is the aperture of the mouth, from which the oesophagus 
extends to the distance of one-fourth to one-third of an inch. The intestine, 
which has a light brownish color, extends from the oesophagus to near the 
posterior extremity of the animal, where it terminates in the anus. The fe- 
males are in numerical excess of the males, and their size is also greater. 
The shape of the worm is like that of the common earth-worm, from which 
it derives the name lumbricus, but it is somewhat more pointed and its color 
paler red. The tail of the male worm is curved like a hook, while that of 
the female is straight. 

The total number of eggs contained in a fully-developed female has been 
estimated at sixty millions. The eggs when immature are conical and are 
attached to a longitudinal band ; when mature they are oval, with dark gran- 
ular contents and a strong double shell, and their diameter is about -^-J-g- of 
an inch. They are expelled in countless numbers with the feces, and at the 
time of expulsion are. surrounded by an albuminous coating stained with bile. 
Their vitality is retained under apparently very unfavorable circumstances, 
even for years. They hatch after they have been repeatedly frozen or 
desiccated. 

The ascaris lumbricoides inhabits the small intestines, where it is rapidly 
developed from the embryonic state. The remark made by Heller, that when 
found in the colon it is always dead, cannot be true, for many live worms are 
expelled in the stools. 

The round-worm, more than ail other intestinal worms, is inclined to wan- 
der away from its usual abiding-place — namely, from the jejunum and ileum 
— producing symptoms of more or less gravity referable to the part over 
which it crawls. It occasionally enters the stomach, from which it is vom- 
ited, or it ascends the oesophagus into the fauces, from which it is soon 
removed by the efforts of the individual. Cases are on record — one of which 
Andral witnessed — in which the worm entered the larynx, producing suffoca- 
tion and speedy death. M. Tonnelle also witnessed such a case. A child 
nine years old was suddenly seized with great difiiculty of respiration and 
pain in the upper part of the chest. A careful examination of the thorax 
gave a negative result. Death occurred in from twelve to fifteen hours, and 
at the post-mortem examination a lumbricus was found filling the cavity of 
the larynx. M. Blandin also witnessed a case when interne of the Hopital des 
Enfants. An infant was suffocated by one of these worms, which had pene- 
trated as far as the right bronchus. Very rarely they crawl from the fauces 



824 INTESTINAL WORMS. 

into the nasal passages. This worm is so strong and active that there is no 
recess or reflexion of the mucous membrane of the digestive apparatus which 
it could possibly penetrate in which it has not been found. It has been dis- 
covered in the appendix vermiformis, in the pancreatic duct, in the common 
bile-duct, and even in the gall-bladder. The nuinber of these worms found 
in the intestines is very various. There may be only one or the number may 
be incredibly large. Thus, Barrier relates the case of an infant thirty months 
old who died in Hopital Necker. It was believed to be tubercular. Numer- 
ous tumors which could be felt in the abdomen were supposed to be tuber- 
cular masses. On making the post-mortem examination the mesenteric glands 
were found healthy, but the intestines throughout their entire extent were 
filled with lumbrici. The masses which during life were supposed to be 
tubercular glands were found to consist of worms. The caecum especially 
was greatly distended by them. The intertwining or collection in balls of 
these worms constitutes, indeed, one of the chief dangers, as it renders them 
so much the more difficult of expulsion. 

The round-worm possesses no organs of penetration ; still, if the intestine 
be weakened by disease, especially by ulceration, it may, by pressure with its 
head, force an opening, through which it escapes into the cavity of the abdo- 
men, causing peritonitis and death. This worm is commonly found, whether 
single or in masses, surrounded by mucus, which serves as a partial protec- 
tion to the intestines. 

The portion of the mucous membrane in contact with lun^brici is often 
found inflamed, either from movements of the worm or from pressure of a 
mass of worms, or even of a single worm in a confined position, as the 
appendix vermiformis. This inflammation, continuing and increasing, may 
end in ulceration, and thus a weakened spot be produced which may be rup- 
tured by simple pressure of the mouth of the worm. In this way are to be 
explained those apparent cases of perforation which have led some observers 
to believe that lumbrici have actually the power of penetrating the healthy 
coats of the intestines. The perforation is obviously most liable to occur in 
those who have been enfeebled and whose tissues have been rendered less 
firm and resisting by antecedent disease, as by typhoid fever. 

M. Guersant describes a case in which the appendix vermiformis con- 
tained an ulcerated opening through which two round-worms had partly 
passed into the abdominal cavity, producing fatal perityphlitis. Q'he eff"ect 
of their impaction in this narrow cul-de-sac was much like that of a bean or 
seed lodged in the same situation. 

The ascaris lumbricoides has occasionally been found in the most remark- 
able locations — namely, in abscesses lying without the intestines. They 
have been known to effect a lodgment in the liver and produce an abscess 
there, no doubt by crawling up and distending a bile-duct. Their lodgment 
in other viscera which have no pervious connections with the intestinal tract 
is probably accomplished through fistulous openings produced by inflamma- 
tion, which they had no part in causing, as, for example, in the bladder and 
kidneys, of which there are well-authenticated cases. Worm-cysts in the 
abdominal walls have been found to occur in most instances in the usual site 
of hernias — namely, at the umbilicus in children and in the inguinal region 
in adults. It is presumed, therefore, that the worms had entered hernial 
protrusions, from which they had passed by ulceration into the abdominal 
walls and had there become encapsulated. 

The oxyuris vermicular is^ or thread-worm, so called from its resemblance 
to pieces of ordinary white sewing-thread, is also frequent in childhood and 
not infrequent in the adult. The length of the male oxyuris is from one- 
sixth to one-fifth of an inch ; that of the female, from one-third to one-half 



INTESTINAL WORMS. 825 

an inch. The posterior extremity of the male is blunt, and is curved or 
rolled up toward its abdomen ; that of the female is slender and pointed 
like an awl. 

The head of this worm is relatively broad, from an unusual thickness or 
fulness of the cuticle, and the mouth, surrounded by " three nodular lips/' 
is situated in the centre of the extremity. The oesophagus extends back- 
ward from the mouth, gradually growing larger like the segment of a long 
and narrow cone, and ending in a globular enlargement which has been desig- 
nated the pharynx. From the pharynx the intestine runs in nearly a 
straight line through the worm. 

The eggs are numerous, so completely filling the interior of the female 
as to conceal the organs from view. They are flattened on one side, but are 
rounded or convex on other parts of their circumference. One end is more 
pointed than the other, as in the eggs of birds. Certain of the eggs in the 
mature female are seen to be undergoing segmentation preparatory to hatch- 
ing, while others more advanced contain tadpole-shaped embryos, and others 
still contain worm-shaped embryos either lying within the shells or protrud- 
ing from them. The hatching and growth of this worm, which have been 
observed under the microscope, are very rapid under favorable circumstances. 
"• I once," says Heller, •' saw the metamorphosis from the tadpole-shaped 
embryo to the worm-shaped embryo completed in about one hour," but the 
usual time is longer. Leuckhart saw oxyurides one-fourth of an inch in length 
fourteen days after the eggs had been swallowed. 

Oxyurides may be developed so rapidly from eggs swallowed in the 
ingesta that they attain nearly or quite their full growth while still in the 
small intestines, so that, although their chosen residence is in the large intes- 
tines, some of them are not infrequently found in the ileum, and even 
in the jejunum, of full size and active. The part of the intestinal tract 
which the oxyurides prefer, and in which the largest colony of them reside, 
is the cagcum and appendix vermiformis, and not in the rectum, as stated in 
most of the books ; and in this situation, where they have been little dis- 
turbed, their habits and the relative proportion of the sexes can be best 
observed. But they are ordinarily found both in the caecum and rectum in 
the same individual, and indeed upon all parts of the intervening surface of 
the colon. 

The number of oxyurides in the individual varies greatly. They are 
occasionally so numerous upon the intestinal surface that they resemble fur, 
and when they are so abundant they are commonly found above the ileo- 
C93cal valve as well as below it. The males are smaller and apparently more 
fragile and perishable than the female. Therefore in the rectum and other 
exposed situations there is a numerical excess of the females ; but in reflex- 
ions of the intestines, where they are securely lodged, as in the appendix 
vermiformis, no marked difference has been observed in the relative number 
of the two sexes. Since the males are more delicate, transparent, and 
smaller than the females, they are more likely to be overlooked in a hasty 
post-mortem examination. 

The term tape-ivorin is applied to several species of the taenia and to at 
least two species of the bothriocephalus, but all except four — to wit, the 
taenia solium, taenia saginata or medio-canellata, taenia elliptica or cucumer- 
ina, and the bothriocephalus latus — are rare in Europe and North America, 
and are therefore of little interest to the practising physician. 

The tape-worm is an hermaphrodite, each segment containing the two 
sexual organs. The head, or scolex, is small, or about the size of a pin's 
head, and segment after segment is produced by a budding process from the 
head. The segments are attached to each other at their extremities, and 



826 INTESTINAL WORMS. 

each segment as it becomes farther and farther removed from the head by 
the formation of new intervening segments at the upper end of the chain, 
becomes also larger and more matured. The oldest segments, having 
attained their full growth, are detached, and have an independent existence. 
A separation of the chain of segments at any point does not compromise the 
life of the parasite. If only the head remain uninjured, the segmentation 
continues from it, and in time the former number of segments and former 
length of the chain are restored. This worm resides in the small intestines, 
the larger species sometimes extending from the upper part of the jejunum 
to near the ileo-caecal valve. 

The tsenia solium is developed from an embryo known as the cysticercus 
cellulosse, contained in the muscles of the hog. It has also been found in 
some other animals, as the dog, deer, and polar bear. It is a vesicle about 
the size of a pea or small bean, having a delicate cell-wall, and is nearly 
spherical, except as its shape is changed by compression between the muscu- 
lar fibres. At one point of the cell-wall is a depression, attached to the inner 
surface of which, and lying within the cyst, is a whitish, pear-shaped, solid 
body, which is the head of the cysticercus, and is identical in appearance and 
character with the head of the taenia solium turned inside out. Many experi- 
ments have shown the close relationship of the cysticercus and taenia solium 
— that they are two forms of existence of the same parasite. Segments of 
the taenia solium have been repeatedly fed to pigs, and the cysticercus pro- 
duced in their muscles, though in what way the ovum or embryo passes 
from the stomach to the muscles is not known. On the other hand, swine 
flesh containing cysticerci has been fed to animals who were soon after killed, 
when the taenia was found in their intestines. It is evident that this parasite 
occurs only in those who eat swine flesh, as sausages, either raw or but 
slightly cooked. 

The head of this species of taenia, which is about the size of a small pin's 
head, has at the top a conical protuberance, upon which is a corona of hook- 
lets, arranged in two circles, the booklets of the outer circle being smaller 
than those of the inner. The projecting points, however, of the two rows 
fall together, forming one circle. The booklets are inserted into depressions 
in the head, and many of them have fallen out in most specimens which we 
have had an opportunity of examining. The depressions in which the hook- 
lets are lodged are often dark from pigmentation. Back of the circle of hooks 
are four sucking discs, which the worm is able to protrude and move freely. 
When protruded they appear as small tubercles with slender pedicles. The 
neck, which is slender and about one inch in length, shows markings from 
commencing segmentation, and it is succeeded by very small and delicate seg- 
ments, which gradually increase in size as the distance from the head increases. 

The mature segments (proglottides) vary in size accordingly as they are 
in a state of contraction or relaxation. When relaxed their length is about 
half an inch and breadth one-quarter of an inch. The genital organs are 
situated on the margin of each segment, a little posterior to the middle, and 
there is an alternation in their location between the right and left margins in 
the chain of segments. The uterus lies in the centre of the segment, form- 
ing a longitudinal straight line. From seven to twelve branches are given 
oft' from each side of the uterus, and these divide and subdivide like the 
branches of a tree. The male genital organs lie in the same aperture or pore 
in the margin of the segment, with which the uterus and ovaries connect. 

The eggs of the taenia solium are globular, with a diameter of about 
_l_th of an inch, and wdth thick shells, which are striated like mosaic-work 
by lines which cross each other. It is estimated that not less than fifty mil- 
lion eggs are contained in all the segments of a matured taenia. 



INTESTIXAL W0B3IS. 827 

This parasite is ver}^ liable to abnormal development. In some instances 
two or more segments are fused together, and often they are stunted in their 
growth, or they contain holes, fissures, and flaws, either from their original 
development or produced b}^ rupture of the distended uterus. Again, rarely, 
two taenia are blended, so that along the flat side of one chain another is 
united by the margin, so that a section of the double parasite resembles the 
Roman letter T or Y. The nutrition of the segments is maintained through 
a vessel running the whole length of the worm near each margin, and having 
•communicating branches. 

The faenia mginafa. designated also mecb'o-canellata ^ is much larger, stronger, 
and thicker, both as regards the head and segments, than the ttenia solium. 
When fully matured it measures eighteen feet. The diameter of the head is 
nearly one line (yf-o inch). It is furnished with four strong sucking discs, 
but it lacks the circlet of hooks which characterizes the taenia solium. Instead 
of the hooks the head is furnished with a small frontal sucking-disc. The 
heads of some specimens of this worm are free from pigment, but other 
.specimens present various shades of pigmentation, from a slight staining to a 
jet black color. The neck is short, and very near the head are markings 
which indicate commencing segmentation. The matured segments vary in 
measurement when relaxed — from a length of eight lines and breadth of two 
lines, to a length of nine lines and breadth of three lines. As in the taenia 
solium, the genital pores are situated on the margins of the segments, vary- 
ing irregularly from side to side, and the uterus has lateral branches which 
divide dichotomously. There is but little diff'erence in the sexual apparatus 
of the t^nia solium and taenia saginata, but the eggs of the latter are some- 
what larger than those of the former, and are oval. 

The development of the taenia saginata is sometimes irregular, producing 
monstrosities, as in the taenia solium. The embryos of this parasite occur 
chiefly in the muscles of ruminating animals, as the ox, sheep, goat, etc., and 
therefore its presence in man is attributable to the use of the flesh of these 
animals either slightly cooked or raw. The cysticercus of this species 
appears to be less tenacious of life than that of the taenia solium, and when 
it perishes it becomes changed into a greenish-yellow pulp, surrounded by the 
capsule and imbedded in the muscular or other tissue where it had lodged. 

It is easy to distinguish this worm from the taenia solium, if the head be 
found, by its larger size, the larger size of its sucking-discs, and the absence 
of the circle of hooks. The segments are distinguished by their greater size 
and greater number, and the dichotomous division of the branches of the 
uterus. This species occurs over a much greater area of the earth's surface 
than the taenia solium. 

The fsenia elliptica or cucumerina is a more delicate worm than the pre- 
ceding species, measuring, when fully grown, from seven to ten or eleven 
inches in length. Upon its head is a rostellum or beak, which the worm is 
able to thrust forward, and on which are about sixty hooks irregularly 
arranged. The anterior portion of the parasite is very delicate, like a thread, 
and its segments are small, but, as in the other species, they become larger as 
their distance from the head increases. The matured segments, which have 
a reddish-white color, are readily detached, and when separated they move 
about actively. This taenia is also an hermaphrodite, and a genital pore con- 
taining a double set of genital organs is located on each margin of the seg- 
ment. The tasnia elliptica inhabits the small intestines of the dog and cat, 
and many children in difi"erent localities have been aff"ected with it. 

Heller states that the segments of another and rare species of taenia, 
which were expelled from a child of nineteen months, are preserved in the 
Museum of Pathological Anatomy in Boston. Nearly in the middle of the 



828 INTESTINAL WORMS. 

posterior half of each segment is a yellow spot — namely, the receptaculum — 
full of ova, and therefore the name flavo-punctata has been applied to this 
worm. Little is known in regard to the taenia nana and taenia Madagascarien- 
sis, since they occur in distant countries. 

The hothriocephahi^ latus is the largest of the tape-worms, attaining the 
length of fifteen to twenty-four feet. It is one of the most important of 
the intestinal parasites. The head has an almond-shape or the shape of 
an elongated and somewhat flattened globe, its length being about one 
line and its diameter from one-third to one-half a line. Running longi- 
tudinally along each flattened side of the head is a groove or fissure contain- 
ing the apparatus of suction. Those segments which are still in the process 
of growth have a breadth three or four times greater than their length, while 
the matured segments are nearly square. The genital pore occurs in the 
centre of one side of the segment, and in the chain of segments all the pores 
are found on the same side. A brownish, rosette-shaped spot is observed at 
the site of each ripe pore, produced by the convolutions of the uterus and 
the numerous eggs which this organ contains. 

The egg, which is oval, has a thin shell, a light-brown color, and at one 
end of it is a lid or operculum which is separated from the rest of the egg by a 
well-defined line. At the hatching an embryo provided with six hooks escapes 
from the lid. When it has separated from the egg it is provided with an albu- 
minous covering, from which cilia radiate in all directions, by the movement 
of which it is propelled. After a few days this covering is lost, and the 
embryo now moves about by amoeboid extension and contraction. It is 
believed that in this embryonic state it enters an aquatic animal, a mollusk 
or fish, where it undergoes further development, and from the mollusk it is 
received into the stomach in the food. 

The bothriocephalus occurs not only in man, but also in some of the 
domestic animals which eat fish, as the dog. This parasite is believed to be 
rare outside of Europe, and in Europe it is chiefly met in countries bordering 
on inland lakes and seas. 

The tricliocepliahis dispar is comparatively unimportant to the physician, 
since it is uncertain whether it materially impairs the health or produces 
symptoms. It inhabits the caecum, but in rare instances it has been found 
in the ileum and appendix vermiformis. The number of these parasites is 
usually small, but as many as seventy to one hundred have been observed in 
the intestine of the adult. 

The trichocephalus dispar occurs also in the monkey, and a very similar 
if not identical worm has been found in the pig. It is not frequent in 
children, and it has not been observed in very young children. It occurs in 
man in every part of the globe, and in some countries, as Egypt, Nubia, and 
Syria, it is said to be very common. This worm, which is also sometimes desig- 
nated the whip-worm from its shape, attains the length of one and a half to two 
inches, the female being longer than the male. Its anterior two-thirds are thin,, 
delicate, and flexible, like a small thread. The posterior one-third, which con- 
tains the generative organs and intestinal canal, is considerably thicker, and it 
ends abruptly. On the under surface, extending nearly the whole length of 
the body, is a longitudinal band, the width of which is about one-third the 
circumference of the body. In the female the posterior or thick portion of the 
worm is slightly bent or curved like the stock of a hunting-whip, while that 
of the male is rolled in the spiral form. The digestive tube consists of an 
cesophagus which extends through the anterior thread-like part, and the 
stomach and rectum, which lie in the posterior thick division. The genitals of 
the female lie in the commencement of the thick portion, and the uterus, when 
distended with eggs, occupies nearly the whole of this section. In the male. 



INTESTINAL WOEMS. 829 

the pore which contains the genitals lies in the posterior extremity of the 
thick part, where it forms a cloaca with the termination of the intestinal 
canal. The eggs, which are numerous, are oval, brownish, and with a glis- 
tening protuberance at each extremity, giving them the shape of a lemon. 
They have great vitality, hatching after repeated desiccation and freezing. 
Their development from the eg^ is slow. It is believed that the trichoceph- 
alus is produced directly from the egg, which has lodged in the intestine, and 
therefore does not have or require an intermediate stage of preparation in 
another animal. This parasite resides in the caecum, but when many are 
present some are found in the ascending colon, and occasionally a few are 
observed in the small intestine. 

The taenia is rare in early life, but it now and then occurs in young chil- 
dren. I have met cases in this city under the age of five years. Rosen and 
Bremser report cases between the ages of six and eleven years, and Hufe- 
land one at the age of six months. Wawruch collected 206 observations of 
taenia, in 22 of which the age was less than fifteen years ; the youngest was 
a girl of three years. A most remarkable case of taenia is reported in the 
Gazette medicale of Paris in 1837. 31. Miiller was called to treat a foster- 
child five days old for slight constipation. The bowels were evacuated by 
the use of rhubarb, manna, and a few grains of salt, and in the excrement 
a foot and a half of taenia were discovered. This worm had evidently existed 
during the foetal life of the infant. 

A similar case was treated by Prof. Skene in the Long Island Hospital in 
September, 1871, and reported by Dr. Armor.^ The infant was born Septem- 
ber 3d of a hearty Irish servant-girl. On the 7th it refused to nurse, and 
was observed to have a mild form of tetanus. On the 8th, small doses of 
calomel having been given, followed by castor oil, two segments of a t£enia 
solium were passed from the bowels, and on subsequent days ten more seg- 
ments, after which the tetanus ceased. The remedies employed after Sep- 
tember 8th were the oil of male fern and turpentine. The mother, who had 
presented no symptoms of taenia, was ordered an emulsion of pumpkin-seeds, 
which '• she faithfully took for twenty -four hours, at the end of which she 
passed over seventy segments of taenia." This case is interesting as throw- 
ing light on a possible mode of the production of taenia quite different from 
the ordinary and recognized mode, and also as showing the causative relation 
of intestinal worms to tetanus infantum. 

Causes. — It is obvious that intestinal worms are developed from eggs or 
embryos which are introduced into the stomach in the ingesta. The eggs of 
the ascaris lumbricoides have been found by Mosler^ in drinking-water, but it 
is probable that in most instances they are contained in fruits and vegetables 
which are eaten raw. The eggs of the oxyuris vermicularis are received 
from some one who is himself affected with the disease. Both Zender and 
Heller state that they have frequently discovered ripe eggs of this worm 
around the nails of persons who were troubled with oxyurides — a fact readily 
explained from the itching which they cause. If these eggs are upon the 
fingers of the mother or nurse, it is easy to understand how they are acquired 
by the child. We can understand also why this worm is so common in 
degraded and filthy families. In reference to the etiology of the tape- 
worm nothing need be added to what has been stated above, and little is 
known in reference to the manner in which the eggs of the trichocephalus are 
received. 

Certain conditions of the intestinal surface favor the occurrence of worms. 
Thus children in advanced typhoid fever are not unfrequently affected with 
the ascaris lumbricoides. 

^ Nev: York M-Aical Journal. ^ Virchoic's Archiv, 1860. 



830 INTESTINAL WORMS. 

Symptoms of the Ascaris Lumbricoides. — These are in part constitu- 
tional and in part local, due to the mechanical effect of the entozoa on the 
coats of the intestines. Writers, especially Rilliet and Barthez, have 
described with minuteness the symptoms supposed to indicate lumbrici. 
Those of a constitutional character are the following : Features at one time 
flushed, at another pallid, and in some children of a leaden hue; lower eye- 
lids swollen, and sometimes surrounded by a blue semicircle ; thirst, nausea, 
or even vomiting ; appetite diminished or augmented or variable ; breath 
foul ; papillae of the tongue red and projecting ; pulse accelerated and irreg- 
ular. Hilliet and Barthez state that they observed this irregularity of the 
heart's action in a boy three years old at the time he was passing a large 
number of lumbrici. The irregularity afterward disappeared. Acceleration 
of the pulse and increase in temperature are common symptoms of these 
worms, and hence the popular belief in a worm fever. This fever is 
often remittent and mild, but occasionally it is continuous and of a high 
grade. 

The symptoms pertaining to the nervous system are important. In mild 
cases these may be absent, as when there are few lumbrici and the child is 
robust and over the age of five years, but in severe cases certain neuropathic 
symptoms are frequently present, such as dilatation of the pupils, especially 
inequality of dilatation, to which Munro attached diagnostic value, strabis- 
mus, twitching of the muscles, clonic convulsions, somnolence, headache, neur- 
algic pains, delirium. Barely chorea, deafness, and paralysis, it is believed, 
may result.^ Dr. Leedom^ of Montgomery county, Pa., relates the case of a 
boy of seven years who had night-blindness due to a large number of lum- 
brici in the intestines. By the employment of pinkroot and calomel these 
were passed and the blindness ceased. Hypersesthesia of the abdominal 
surface was present in a case which I attended, and which subsided as soon as 
the lumbrici were expelled. Grinding the teeth in sleep and picking the nos- 
trils are symptoms to which families attach great value. Observations, how- 
ever, show that though sometimes due to worms they more frequently have 
another cause. 

The local symptoms or disorders — in other words, those having a mechan- 
ical origin — are colicky pains, experienced chiefly in the umbilical region ; 
stools sometimes natural ; in other cases diarrhoea with fecal or muco-san- 
guineous stools ; flatulence. M. Davaine at a recent period made the import- 
ant discovery that the feces of patients aflected with worms contain the ova 
of the particular species present in large numbers. These ova, which have 
been described above, can be seen through a lens magnifying one hundred and 
fifty diameters. 

In exceptional cases there are local symptoms, due to the presence of 
these worms in unusual situations, such as a crawling sensation in the oesoph- 
agus ; a sense of constriction in this tube or the pharynx ; nausea and vomit- 
ing ; a cough, especially if the worm have crawled to the upper part of the 
oesophagus ; rarely the most urgent dyspnoea and probable suffocation if 
a lumbricus have entered the larynx. Earache and perhaps convulsions if 
the worm have entered the Eustachian tube (case Davaine, p. 144). The 
most dangerous symptoms arise from the crawling of the worm into narrow 
openings. 

The enteritis and colitis to which these worms sometimes give rise are 
ordinarily mild, but in rare instances ulceration occurs, which may be attended 
by profuse and even fatal hemorrhage. Occasionally very painful and 
dangerous constipation results from an accumulation of worms in a ball or 
mass too large to be expelled, unless with much delay and suffering, prevent- 

^ Gaz. des Hopitaux, 1867. ^ Amer. Jour, of Med. Sci, for July, 1867. 



INTESTINAL WORMS. 831 

ing the passage of fecal matter and producing severe abdominal nains. The 
symptoms in these cases resemble closely those of intussusception. A marked 
example of constipation produced in this way occurred in a family with whom 
I am acquainted and who then resided in the interior of this State. A little 
girl of three or four years was suddenly affected with obstinate constipation. 
The physicians prescribed active purgatives, calomel among others, and finally 
croton oil and various injections, without relief. There was great pain with 
distension of the abdomen, and death seemed inevitable, when after the lapse 
of several days a free evacuation occurred, and in the stool was a mass of 
worms firmly intertwined. 

Children often have lumbrici without any appreciable impairment of the 
general health, but their presence may intensify the symptoms of intercur- 
rent diseases and greatly increase the danger. Thus I recollect two children 
of three and three and a half years with pneumonia who at the same time 
had lumbrici, one passing in the course of a few days thirty and the other 
twelve of these entozoa. Both presented well-marked physical signs of 
pneumonia, and, though they recovered, the fever and nervous symptoms 
were apparently aggravated by the intestinal affection. One had convulsions 
in the commencement of the inflammation, followed by profound stupor and 
amaurosis lasting two or three days. 

Often the symptoms due to lumbrici coexist with those of a protracted and 
distinct intestinal disease. Thus, as we have seen, the intestinal secretions 
of typhoid fever and of chronic diarrhoeal maladies afi"ord a nidus for the 
growth of worms, and accordingly at an advanced stage of these diseases 
lumbrici are common. 

The symptoms produced by the oxyurts vermicularU are somewhat differ- 
ent. These worms do not usually cause the fever, disturbed digestion, the 
colicky pains, or the dangerous nervous symptoms which arise from the 
presence of lumbrici. Nor do they, like lumbrici, endanger life by crawl- 
ing into unusual situations. In one recent case I could detect no other cause 
of chorea than the presence of oxyurides, and eclampsia has been attributed 
to them, but such a result is exceptional, if indeed the cause be rightly 
assigned. 

Although the caecum is the chosen abode of this worm, and here more 
than elsewhere it exists in its normal state, it is not certain that it produces 
any appreciable symptoms in this part of the intestinal tract. 

The symptoms which render this the most annoying of all the intestinal 
parasites are produced by these oxyurides, chiefly the females, which descend 
into the rectum, where by their active movements they produce intense 
itching. A small number of worms cause little inconvenience, but when 
many are present in the folds of the rectum their crawling produces such 
intense pruritus that the patient can with difficulty remain quiet. Usually 
this symptom is most marked in the early evening, when the child is warm 
in bed. It sometimes causes onanism in the girl as well as boy. This symp- 
tom maj' be nearly or quite absent during the day, but it returns so regularly 
at night as to resemble and be mistaken for a periodical nervous affection. 
So eminent a physician as Cruveilhier confesses that he has made this mistake 
of diagnosis. In the female child the oxyuris occasionally passes from the 
rectum to the vulva, producing leucorrhoea. 

In many instances tape-worms exist in children as well as adults who 
thrive and present no symptoms, but in other instances there is more or less 
disturbance of the digestive function, with an uncomfortable sensation in the 
abdomen. This sensation is more noticed after fasting or after the use of 
certain kinds of food, and it is diminished by a full meal. Great hunger and 
a feeling of faintness are also common, according to authorities, but I have 



832 INTESTINAL WORMS. 

not particularly remarked them in children. Irregular action of the bowels, 
vomiting, and various nervous symptoms, as itching of the nostrils and anus, 
headache, tinnitus aurium, cardialgia, numbness, deafness, blindness, etc.. 
have with more or less correctness been attributed to the tape-worm. Cer- 
tainly, such symptoms occasionally arise from this cause, for they cease with 
the expulsion of the worm.^ Intermittent colicky pains in the umbilical 
region were the only marked symptoms in a child with taenia which I recently 
treated. Since the cysticercus cellulosse is the embryonic form of the taenia 
solium, it is quite possible that individuals possessing the latter may be 
infected from its ova with the former, so that symptoms which have been 
attributed to the intestinal parasite have sometimes been due to the encysted 
embryo. We are unacquainted with the symptoms of the trichocephalus, if 
any occur, and this worm is very rare in children. 

Diagnosis. — Bremser long since made the remark — and it has been 
repeated by most writers on diseases of children — that there is no sign or 
symptom which affords positive proof of the presence of intestinal worms 
except the expulsion of one or more. In recent years, however, microscopic 
investigations have revealed a pathognomonic sign — namely, the presence of 
ova in the feces, which indicates not only the nature of the disease, but the 
species of the worm. 

The symptoms and disorders produced by lumbrici may all occur from 
other causes. Still, if several of them be present and a careful examina- 
tion disclose no other cause, the presence of worms should be suspected, 
provided that the child be over the age of two years. The microscope may 
then be used for diagnosis. A little tentative treatment, entirely safe to 
the child, will also determine whether the suspicion be correct. One or 
two doses of medicine, administered under such circumstances, like the 
surgeon's exploring-needle may reveal the nature of the disease and indicate 
the means of cure. 

In the case of the oxyuris vermicularis the itching directs attention to 
the anus as the place of the disease, and here the offending entozoa may often 
be discovered by the eye. 

Prognosis. — Intestinal worms produce a fatal result in only a small 
proportion of cases. Oxyurides never prove fatal, unless in rare instances 
through convulsions. The manner in which death may be produced by 
lumbrici has already been pointed out. 

In general, when the nature of the disease is ascertained the worms are 
readily expelled by treatment and the patient restored to health. Therefore, 
if there be no complicating disease the prognosis is good. 

Treatment. — Much injury has been done to children by the use of 
anthelmintics occasionally employed by physicians, but oftener by parents 
before the physician is called. Medicines of this kind are usually irritants, 
and, in many of those diseases which simulate the verminous affection, but 
are distinct from it, there is already an irritated if not an inflamed state of 
the intestinal mucous surface. 

Vermifuges administered under such circumstances obviously do harm, 
and in all acute diseases in which they are not required, even if their action 
be harmless, their employment is to be* regretted, since it consumes time, 
which is very precious. It is thus that many lives are lost by the use of 
anthelmintic nostrums which are extensively advertised and which com- 
mand a ready sale, inasmuch as the belief in the presence of worms as a 
frequent cause of disease pervades all classes. 

A safe rule, followed by many physicians — and it would be much better 
if it were general — is not to give anthelmintics unless the child have passed 

^ Medico-Chir. Rev., January, 1868. 



TREATMENT. 833 

one or more worms or their ova be found in the feces, and not then if the 
symptoms seem to be referable to a coexisting disease. In doubtful cases in 
which the symptoms resemble those of worms a purgative dose of calomel 
or calomel and rhubarb may be employed. It will generally bring away one 
or more lumbrici or a mass of ascaris vermicularis if either species of entozoa 
be present. This purgative may be safely employed if there be no previous 
diarrhoea or debility. If after one or two doses and a free purgation no 
worms be passed, anthelmintic remedies should not be given, for it is almost 
certain that none exist. 

A large number of medicines have been employed for the purpose of 
expelling lumbrici. Santonin, the active principle of the European wormseed, 
is one of the best, and is much employed in this country and in Europe. It 
is nearly tasteless ; it may be given in powder spread on bread with butter. It 
is kept in shops in one or two-grain lozenges, with and without calomel. It 
has the advantage of easy administration, and is destructive to both the 
round- and thread-worm. M. Bouchut considers it preferable to all other 
remedies in the treatment of the round-worm. " To children two years of 
age he administers it in doses of ten centigrammes (1.54 grains), and in 
patients above this age the cjuantity is increased by five centigrammes (0.75 
grain) for every additional year." He gives in addition occasional doses of 
calomel or castor oil. In this country santonin is usually administered in 
one to three-grain doses once or twice each day, with an occasional purga- 
tive. The purgative is required to aid not only in the expulsion of the worm, 
but also of the ova. In over-doses santonin causes vomiting, diarrhoea, and 
altered vision, so that objects appear yellow, but in medicinal doses it pro- 
duces no unpleasant consequences. Other medicines are preferable if there 
be symptoms of enteritis. Treatment by santonin from two to three days 
sufiices. For many years the anthelmintic most employed in this country 
was the pinkroot, the root of the Spigelia marilandica^ an indigenous plant. 
It was not only prescribed by physicians, but employed by families as a 
domestic remedy. It is liable to cause, if the dose be large, cerebral symp- 
toms, as vertigo, dimness of sight, spasm of the facial muscles, stupor, and 
even, convulsions. These effects less frequently occur if the pinkroot be 
given with a purgative, and it has been customary to administer it in com- 
bination with senna in an infusion. A half ounce of spigelia with an equal 
quantity of senna is macerated for two hours in a pint of boiling water and 
then strained. For a child two or three years old the dose is half an 
ounce to one ounce. So popular has this vermifuge been in this country that 
probably a majority of the native-born old people in the States recollect the 
nauseating doses of pinkroot administered by anxious parents. Pharmacy 
now provides us with the same medicine in a more convenient and acceptable 
form, that of the fluid extract: 

R. Fkiid. ext. spigel., f .^ j ; 

Fhiid. ext. sennse, f^ss, Misce. 

One teaspoonful to a child from three to five years. 

The officinal fluid extract of spigelia and senna may be given in the same dose 
as the above. Professor Proctor recommends the addition of santonin to this 
extract : 

R. Fluid, ext. spigel. et sennje, f§j ; 

Santonin, gr. viij. Misce. 

This is probably the best anthelmintic that can be employed for the 
destruction of the round-worm in uncomplicated cases, and it is also very 
useful in treating the ascaris vermicularis. Chenopodium is also a good 
53 



834 INTESTINAL WORMS. 

anthelmintic. It is efficient, and at the same time one of the safest in case 
the mucous membrane be inflamed. If there be abdominal tenderness, with 
stools too frequent and thin or mucous and tinged with blood, I should prefer 
the chenopodium to most of the other vermifuges. To a child of three years 
five drops of the oil may be given three times daily. It may be continued 
for a longer period than would be safe for most of the other vermifuges. 
Twice a week, during its use, a mild purgative should be given, as castor oil, 
rhubarb, or magnesia, unless the bowels are open. It may be given dropped 
on sugar or in a mucilaginous mixture. 

Dr. J. F. Meigs says : " I myself rarely give any other remedy than 
wormseed oil in slight and especially in doubtful cases, unless this has already 
been tried and failed. From my own experience I believe that this remedy 
is all-sufficient in a large majority of the cases that occur in this city, as these 
are almost always of a mild character, and as it not only produces the expul- 
sion of the parasites when they exist, but also acts beneficially upon the 
forms of digestive irritation which simulate so closely the symptoms pro- 
duced by worms. I am persuaded, indeed, that of all the cases that have 
come under my notice in which it seemed probable that worms might be 
present, none were expelled in nearly half, and yet the signs of disturbed 
health have passed away under the use of the remedy." . . . . " The follow- 
ing is a very good formula for the administration of this remedy : 

" R. 01, chenopodii, gtt. Ix vel f^j ; 

P. g. acacise, ,^ij ; 

Syrup, simplic, 5J ; 

Aq. cinnamom., %\]. Misce. 

Give a dessertspoonful three times a day for three days, and repeat after several days." 

In cases of protracted intestinal disease attended by an increased and 
vitiated secretion from the mucous surface, a state which often gives rise to 
worms, turpentine is one of the best anthelmintics. In fact, in some of these 
cases there is no good substitute for it. For example, a boy of about ten 
years, attended by myself, October, 1864, had reached or nearly reached the 
fourth week of typhoid fever, when he passed from his bowels a large quan- 
tity of blood. He was previously emaciated and weak, and there had been, 
as is usual in such cases, considerable diarrhoea. The hemorrhage was 
attended with great prostration, from which, however, he partially rallied by 
the use of stimulants. On the following day an equally severe hemorrhage 
occurred, attended with coldness of the face and extremities and great feeble- 
ness of pulse, so that death appeared imminent. Turpentine was now admin- 
istered every six hours, a few lumbrici were passed, and the case thenceforth 
progressed favorably. The mechanical effect of the lumbrici on the ulcerated 
surface of intestine had probably given rise to the hemorrhage. Turpentine 
may be given in doses of from five to ten minims three times daily to a child 
five years old. Sweetened milk or sugar in powder is a good vehicle for it, 
or it may be given in a mucilaginous mixture. 

R. Spts. terebinth, rec, ^ij ; 
01. limonis, gtt. v ; 

Mucil. gum acac, 

Syr. simplic., da. .^vj ; _ 

Aq. anisi, oii~iy- Misce. 

Dose : One teaspoonful every six hours. 

The following formula for the employment of this agent is recommended by 
Dr. Condie : 



R. 



TREATMENT. 




Mucil. gum acac, 


lij; 




Sacch, alb., 


5x; 




Spts. pether. nitr., 


.5iy ; 




Spts. terebinth, rect., 


.^iij i 




Magnes. calcinat., 


?)y. 




Aqnse menthse, 


I]- 


Misce. 



835 



It is useless to enumerate the many anthelmintic mixtures wliicli have 
been extolled from time to time. Those mentioned above are the least 
nauseous, and rarely disappoint the practitioner. One other antidote for the 
round-worm should be mentioned, as it has been much used and is efficient — 
namely, cowhage. This consists of the bristles which cover the pods of the 
Mucuna pruriens^ a tropical plant. The pods are dipped in plain syrup of 
the ordinary consistence, and the bristles are scraped off with the syrup. 
When enough of the medicine is added to render the syrup of the consist- 
ence of thick honey, it is ready for use. The dose is a teaspoonful every 
morning for three days, after which a cathartic should be administered. I 
have never prescribed cowhage, although it is not unfrequently ordered by 
physicians, and a popular nostrum consists chiefly of it. 

One affected with tape-worm is obviously cured only when the head of 
the parasite is expelled ; but in the majority of cases which I have observed 
the head has not been found in the evacuations, even when the treatment 
had effected a complete cure, as shown by the subsequent history. The 
chain of expelled segments commonly terminated very near the head. 
This I believe is the common experience, if we trust the friends of the 
patient with the examination of the stools. The physician himself should 
search for the worm's head, the evacuations being preserved. The nurse 
should be directed to add a little carbolic or salicylic acid, and a sufficient 
quantity of water to nearly fill the vessel. The liquid should not be roughly 
stirred with a stick, as physicians are in the habit of doing, since this breaks 
the worm into small portions and renders the inspection more difficult, but it 
should be shaken frequently, so as to detach the segments and head, if it be 
present, from the fecal matter. After it has stood at least five or ten min- 
utes, the worm, which has greater specific gravity than water, sinks to the 
bottom, and the upper part should be poured off. This process must be 
repeated till the water is nearly colorless, after which search should be made 
for the fragments, and the head, if present, will be found. 

Since entire expulsion of the tape-worm is effected with difficulty, pre- 
paratory treatment for about forty-eight hours should be employed before 
the vermifuge is administered. During this time the patient should take a 
mild purgative once or twice, and such food, in moderate quantity, should be 
allowed as leaves little residuum, as beef tea, milk, etc., with some stimulant 
if the patient feel exhausted. There are three articles of food which expe- 
rience has shown to be especially useful in this preparatory treatment, per- 
haps from a sickening effect which they produce upon the worm — namely, 
salt herrings, onions, and garlic. They may therefore be taken as food in 
the twelve or eighteen hours preceding the employment of the vermifuge, 
which it is ordinarily most convenient to administer in the morning. 

The various taenicides recommended in the books are probably all more or 
less efficient, but the one which has given most satisfaction in the Out-door 
Department at Bellevue, where probably a larger number of these cases are 
treated than in any other place in this country, is the oil of male fern ; but 
it is found necessary to employ a larger dose than is recommended in some 
of the books. For a child of six years the dose employed is one drachm in 
any convenient vehicle, as the syrupus aurantii florum. This should be fol- 
lowed in about four hours by a dose of castor oil, which completes the treat- 



836 • INTESTINAL WORMS. 

ment. Heller, a liigli German authority, recommends koosso or its active 
principle koossin, in the use of which I have had no personal experience. 
The pumpkin-seed has also been employed at Bellevue and in other parts of 
this city, but it seems to be less efficient than the oil of the fern. If the 
chain of segments break near the head and the head be not seen, it will be 
necessary to wait two or three months in order to determine whether the 
cure is complete. 

The medical journals during the past year have published and extolled 
the following formula for the treatment of the tape-worm. It is so difficult 
to expel the head, and taenicides employed singly so often fail in accomplish- 
ing this result, that so powerful a combination of taenicides deserves consid- 
eration, and perhaps trial. The dose recommended is probably for the adult, 
but a proportionate dose could be given to a child : 

R, Granati corticis radicis, ,^ss; 

Seminarum peponis, Jj ; 

Pulveris ergot se, .^j ; 

Aquse BuUient, ^viij. Misce. 



Fiat infus. 



Fiat eraulbionera. 



R. Extracti filicis maris eetheris, fjj ; 

Ol. tiglii, n^ij; 

Pulveris acacise, ^^^ij. Misce. 



Mix the emulsion with the infusion and give them at 10 A. M. A full dose 
of Rochelle salts should be given the previous evening, and no breakfast 
taken. 

We should hesitate to administer so powerful a remedy to a child under 
the age of eight years. Perhaps it might be best to recommend one-quarter 
or one-third of the above dose to a child of eight years, and half the dose to 
one of twelve or fifteen years. 

Since the symptoms produced by the oxyuris vermicidaris are referable 
chiefly to the rectum, and are caused by the active movements of the worm, 
the prompt and thorough use of enemata, which causes their expulsion, is 
evidently required. Enemata are more eflectual if used cool than if warm ; 
and since this worm inhabits the caecum as well as rectum, large enemata 
given through a long tube or a large catheter are more effectual, causing the 
expulsion of a larger number of worms than are expelled by small enemata 
employed in the usual manner. Various sub.stances have been used for this 
purpose, as lime-water, table salt in water, turpentine in milk, decoction of 
aloe, decoction of garlic, etc. Heller says : " Simple water would do well for 
this purpose, for in a short time it causes the worm to swell up and burst ; 
but it is not altogether without an injurious effect on the intestinal mucous 
membrane. Hence, Vix recommends a solution of castile soap in distilled 
water or rain-water of the strength of one to two and a half grains to the 
ounce. This has no unpleasant action on the intestinal mucous membrane, 
while at the same time it quickly destroys both the worms and their eggs. 
.... Vix has tested all the medicines usually used in enemata, and has 
found the above solution of castile soap to be the most effectual." The use 
of the enema in the evening, although only a small quantity of liquid be 
employed, so as to wash out the rectum, ensures relief from the itching and 
sleeplessness during the night. 

But it is undeniable that enemata alone do not effect a complete and per- 
manent cure in a large proportion of cases, and hence those affected with this 
worm remain sufferers for years ^ having only a temporary respite, unless 



INTUSSUSCEPTION WITHOUT SYMPTOMS. 837 

medicines be administered by the mouth. Those medicines which produce 
free watery evacuations appear to be the most effectual in dislodging and 
expelling oxyurides, whose attachment to the intestinal surface is not 
strong; therefore Heller recommends the saline purgatives "joined with 
copious draughts of water." The solution of magnesium citrate found in 
the shops is useful for this purpose. 



CHAPTER XII. 

INTUSSUSCEPTION. 

Intussusception, or the passage of one portion of intestine into another, 
has long been known as an occasional accident. Hippocrates, though debarred 
from the study of morbid anatomy, appears to have had a pretty clear idea 
of this displacement, and he suggested a mode of treatment which has been 
employed till the present time. 

Intussusception without Symptoms. 

This is not properly a disease. It consists in a displacement without any 
other anatomical change. There is, therefore, no obstruction, inflammation, 
or even congestion present, and no symptoms. This form of invagination 
might ordinarily be reduced by the normal peristaltic and vermicular move- 
ments of the intestine. 

Invagination of a portion of the small intestine into the part immediately 
below it is often observed at the post-mortem examination of young infants 
who had presented no symptoms due to the displacement. The invaginated 
mass is usually from half an inch to two inches in length, and as a rule this 
accident is multiple. There may be ten or more distinct intussusceptions at 
distances of a few inches from each other. The simple displacement is 
believed to occur ordinarily at or a short time prior to the moment of disso- 
lution. It has been supposed to be most frequent in those who have died of 
cerebral or spasmodic diseases, but its occurrence is not unusual in other 
pathological states. I have often found it at the post-mortem examination 
of infants who have had subacute or chronic entero-colitis. Heven states 
that he has seen itat the Salpetriere more than three hundred times. Billard 
has seen it especially in infants who have been subject to constipation. Any 
irritant, mechanical or other, which disturbs the regular movements of the 
intestines doubtless may produce it. It has been caused in the rabbit by 
irritating the anus. 

It is not improbable that simple intussusception occasionally occurs tem- 
porarily in children whose health remains good when the regular movements 
of their intestines are disturbed by irritating ingesta or other causes. This 
form of displacement never takes place in the large intestine. Its usual seat 
is the lower part of the jejunum and upper part of the ileum. Since it pos- 
sesses little interest as regards pathology, and none whatever as regards 
symptomatology and therapeutics, it may be ignored in our description of 
intussusception. 



838 INTUSSUSCEPTION. 

Intussusception with Symptoms. 

Intussusception, or invagination, is one of the most painful and dan- 
gerous of human maladies, but fortunately is not very frequent. I have the 
records of 52 cases occurring in children in addition to the records of sev- 
eral cases more recently observed. From these the facts contained in this 
chapter are chiefly derived. The patients were under the age of twelve years. 

Previous Health. — In 34 of the 52 cases the state of the health pre- 
viously to the invagination was recorded. From the following table it is seen 
that one-half, or 17, were previously well, the remaining half suffering from 
some disease or derangement : 

Previous Health. 



Age. Good. Disease or Derangement. 

One year or under 15 8 

Over one year 2 9 

17 17 

MM. Rilliet and Barthez, whose views in reference to intussusception are 
derived from the examination of the records of 25 cases, state that the pre- 
vious health is ordinarily good, and the intussusception is therefore primary. 
Their remark, according to the above statistics, is seen to be correct as regards 
patients under the age of one year, but incorrect for those over that age. 

Most of the 17 who had previous ill-health had diarrhoea, dysentery, or 
constipation, or diarrhoea alternating with constipation. Of those otherwise 
affected, 1 had thread-worms, 2 obscure abdominal pains, 1 nausea and vomit- 
ing, and 1, whose age was four months, had had symptoms of invagination 
when ten weeks old, which soon passed off. It is seen that the pre-existing 
affections were ordinarily such as would be likely to accelerate the movements 
of the intestines and at the same time render them irregular. 

Causes. — The above statistics, therefore, show that intussusception is 
often preceded by disease or functional derangement of the intestines. The 
two opposite conditions — namely, constipation and the diarrhoeal maladies — 
so often precede the displacement that they must be regarded as common 
causes. Another .probable cause is intestinal worms, which by their mechani- 
cal action stimulate the intestines. They were present in 3 of the 52 patients, 
though 2 of the 3 seemed well till the occurrence of the intussusception, but 
the other patient had complained of irritation at the anus, and ascarides had 
been found on examination. 

The use of irritating and indigestible food is an occasional cause. Thus, 
some who have had intussusception have been in the habit of taking fruits, 
candies, and pastries freely. Such ingesta may be an immediate cause by 
their irritating effect, or a remote cause giving rise to diarrhoea, which in turn 
produces intussusception. 

Sex is a predisposing cause, since male patients are largely in excess. 
Of the 25 cases collated by Rilliet and Barthez, all but 3 were boys. In 
our own collection the sex of 34 of the patients was recorded, and of these 
23 were boys. 

In rare instances external violence is the apparent exciting cause. One 
patient received a severe contusion of the abdomen two years before death, 
and from this time continued to complain at intervals of pain in the bowels. 
One writer also mentions the case of a child nine years old, who received a 
blow from a comrade at school, and from this time had alternately diarrhoea 
and constipation till the invagination commenced. Rilliet and Barthez also 
relate the cases of two children who were taken suddenly with invagination 
when their parents were tossing them in their arms. 



INTUSSUSCEPTION IN THE SMALL INTESTINES. 



839 



Age. — Of the 52 cases embraced in our statistics, the ages were as 
follows : 



3 were 3 months old. 



12 " 4 
3 " 5 
5 " 6 
1 was 7 

1 " 8 
3 were 9 



1 was 10 months old. 
1 " 11 " 

1 '' 12 " 

2 were from 1 to 2 years old. 
8 " " 2 " 5 " 

8 " '-5 " 12 " " 



Therefore, no cases occurred under the age of three months ; 23 cases were 
between the ages of three and six months, or nearly one-half of the entire 
number ; 8 between the ages of six months and one year ; and only 18 between 
the ages of one year and twelve. These statistics correspond, in the main, 
with those of Rilliet and Barthez, in whose collection of 25 cases no one was 
under the age of four months. Leichtenstern ^ says : " Half of all invagina- 
tions, according to my statistics of 473 cases, occur during the first ten years. 
The first year after the third month is remarkable for a special frequency — 
one-fourth of all intussusceptions." 

The great liability to intussusception in infancy is due partly to the ana- 
tomical character of the intestine in this period of life, and partly, doubtless, 
to the fact that there are more frequent irregularities in the intestinal move- 
ments than in older children. In the infant the walls of the intestines are thin, 
the mucous and muscular coats and the connective tissue being much less 
developed than in those that are older; the mesentery and meso-colon have 
also greater depth as compared with the same in other periods of life, except 
the meso-colon at the points where it passes over the kidneys, in which places 
it is very short or even in some cases nearly absent. Moreover, the space 
occupied by the large intestine, in which part of the digestive tube intussus- 
ception commonly occurs, is much shorter relatively to the length of the 
intestine than in those that are older. In about thirty measurements which 
I have made of the length of the large intestine and the space occupied by 
it, the latter was found, on the average, about one-third that of the former, 
which of course necessitates doubling of the intestine on itself. These pecu- 
liarities of structure in the infant obviously favor the occurrence of intus- 
susception. 

Seat and Pathological Anatomy. — While intussusception occurring 
without symptoms is usually multiple, that form which occurs with symp- 
toms is ordinarily single. Two exceptional cases which I observed will be 
presently related. In one of the cases embraced in the statistics an invag- 
ination occurred with symptoms, and coexisting with it was another in 
the small intestines apparently without symptoms and quickly reduced by 
handling. 

While intussusception without symptoms occurs in the small intestine, 
the seat of intussusception with symptoms is, with occasional exceptions, the 
colon. The colon constitutes the entire invaginated mass, or else and more 
frequently it forms the exterior, while the incarcerated portion consists wholly 
or in part of the ileum. 



Intussusception in the Small, Intestines. 

Bouchut says : " M. Rilliet states in a recent treatise that in infancy the 
intestinal invagination is always accomplished at the expense of the large 
intestine, and that there is never invagination of the small intestine. This 

^ Ziemssen's Encyclop. 



840 INTUSSUSCEPTION, 

is incorrect. I have observed the small intestine invaginated in the adjacent 
inferior part. Taylor has reported a case of this kind in a child twenty 
months old who died after an attack of acute peritonitis. M. Marage has 
seen another case in a child thirteen months old, who recovered after having 
voided the invaginated portion furnished with two of those diverticula so 
frequent in the small intestine of the foetus." 

But, from all that appears, the case reported by M. Marage may have 
been, and probably was, an example of the common form of intussusception — 
to wit, the prolapse of the ileum into the colon. In Mr. Taylor's case the 
invagination was really of the ileum into the colon, although a small por- 
tion of the ileum next to the valve had not been inverted, so that it con- 
stituted a little of the exterior of the mass. 

Nevertheless, Bouchut is correct in stating that irreducible and fatal 
intussusception may occur in the small intestines. Probably the displace- 
ment is at first of the simple variety, but, continuing and increasing in 
extent, its return becomes impossible. The positive statement of so great 
an authority as M. Rilliet, that intussusception with symptoms does not 
occur in the small intestines, justifies the publication of the following cases, 
which establish the fact that there are instances, though not frequent, in 
which the displacement does have this location : 

Case 1. — This patient's health had been uniformly good, and nothing unusual 
was observed in his condition till the age of four and a half months, when he 
became restless, as if in almost constant pain, with occasional exacerbations. 
Castor oil was prescribed, which operated freely, and then the following mixture : 

R. Magnes. calcinat., 9j ; 

Tinct. opii camphorat., ^ij ; 

Tinct. asafoet., ,^ss; 

Aq. anisi, Jj. Misce. 

Dose : Ten to twenty drops, repeated according to the pain. 

These remedies failed to give relief, as did also chloroform given in doses of 
two drops. After two or three days another set of symptoms arose, those cha- 
racteristic of pneumonia — to wit, hurried respiration, accelerated pulse, short 
suppressed cough, and expiratory moan. He was treated with the oiled-silk 
jacket and mild counter-irritation, and took an expectorant mixture containing 
ammonium carbonate. In a few days the pulmonary disease was evidently sub- 
siding, but the pain in the abdomen, with occasional exacerbations, continued. 
His countenance was pallid and bore an expression of suffering. There was no 
distension or tenderness of abdomen and no abdominal tumor. He took little 
nutriment and seldom vomited. In the last part of his sickness the dejections 
were scanty, and the last three days his stools consisted mainly of muciis and a 
little blood. The pain seemed to be growing less when he was seized with con- 
vulsions, and died the same day, precisely two weeks from the commencement 
of his sickness. 

Sectio Cadaver. — Head not examined ; body slightly emaciated ; mucous 
membrane of trachea and bronchial tubes vascular ; posterior portion of the 
lower lobe of each lung solid, of greater specific gravity than water, and allow- 
ing only partial inflation ; it was in the second stage of pneumonia. Stomach, 
duodenum, jejunum, healthy. In the upper part of the ileum was an intussus- 
ception two-thirds of an inch long, presenting no trace of inflammation either 
within or around it, and its vascularity, when it was examined externally, did 
not seem notably increased. Above the intussusception the intestine was empty; 
below it, and chiefly in the small intestine, was a dark-colored substance, evi- 
dently blood, and giving in a few hours the offensive odor of decaying animal 
matter. There was a passage through the intussusception at least two^ or three 
lines in diameter, as shown by a probe. The intussusception sustained the 
weight of sixteen inches of the intestine, and it would have apparently sustained 
considerably more. The remaining organs were healthy. 



INTUSSUSCEPTION IN THE SMALL INTESTINES. 



841 



Case 2. — F. S , a female infant four months old, was treated at the 

New York Infant Asylum in June and July, 1865, for entero-colitis, the usual 
epidemic of the summer season. The following records show the state of the 
bowels immediately before her death: 

June 29th : Has five or six stools daily. 30th : Two stools in twenty -four 
hours. July 1st : Had two stools since the last record ; no vomiting. 3d : Four 

Fig. 47. 




stools in last twenty-four hours. 4th : The diarrhoea continues, as before ; the 
stools about four daily. On the 6th of July she died. 

Her pulse during the time in which these records were taken generally num- 
bered about 128 per minute. She was much emaciated, and the day before death 
she frequently struck her head with her hand. The medicines employed were 
mainly alkalies and astringents. 

Sectio Cadaver. — Parietal bones united ; serous effusion over the convolutions 
of the brain, under the arachnoid ; occipital bone depressed ; commencing at a 
point about two feet below the stomach were four intussusceptions two or three 
inches from each other. The invaginated masses were from one to one and a 
half inches in length, and three of them were found to be very vascular in their 
interior. Above, between, and immediately below the intussusceptions the intes- 
tine was healthy. One of the invaginations was tested by weight, and was found 
to sustain a foot and a half of intestine, and would have sustained more. Water 
poured above these intussusceptions escaped through them very slowly ; no 
fibrinous exudation ; descending colon vascular and thickened and solitary 
glands enlarged. 

The irreducible character of the intussusceptions in the above cases was 
shown by the fact that they sustained weights which doubtless produced 
greater traction than that exerted by the intestine in its normal action. 
That the displacement existed prior to the moment of death was shown by 
the symptoms in one of the cases and by the anatomical changes in both. 
In one the capillaries of the incarcerated mass were ruptured during the 
last days of life, so as to produce sanguineous stools, while in the other 
there was intense congestion of the invaginated mucous membrane, and 
that portion of this membrane which was adjacent, but not engaged, was 
healthy. 

In both patients the symptoms were less severe than in ordinary cases, and 



842 INTUSSUSCEPTION. 

they came on more gradually, for the invaginated intestine was not com- 
pletely closed, so that it allowed the passage of fecal matter in one till the 
close of life, and in the other till near its close. At both of the autop- 
sies water poured into the intestines above the invaginations passed slowly 
through them. 

Intussusception in the small intestines in the infant, commencing as the 
simple form, may become irreducible, and yet, remaining pervious, may con- 
tinue for weeks without giving rise to severe or dangerous symptoms. The 
following case was an example of this : 

Case 3. — Male child, died at the age of nineteen months, the last eleven of 
which he was under observation. The mother states that he had never been 
well since the age of one month, and that there had been little variation in the 
symptoms of his disease. During the period in which he was under observation 
he was ordinarily fretful, and frequently seemed to be in considerable pain. His 
stomach during this whole time was so irritable that he rarely took more 
than three or four spoonfuls of nutriment without vomiting. There was usually 
more or less diarrhoea, but no tenderness or distension of abdomen. He became 
slowly but gradually more emaciated, and finally died in a state of extreme 
emaciation and exhaustion. He had no convulsions, and was conscious to the 
last. 

Sectio Cadaver. — Brain not examined ; lungs healthy, except a circumscribed 
portion which was inflamed at the summit of the right lung ; liver small and 
almost destitute of oily matter, as shown by the microscope. In the jejunum, 
about two feet below the stomach, was an intussusception two inches long, the 
intestine forming which seemed to have undergone no structural change. Above 
the intussusception the intestine was of small calibre, and entirely empty and 
pale ; below the intussusception the intestine was somewhat larger than above, 
but it seemed quite healthy. The invagination was sufficiently pervious to allow 
water to pass through it, and it readily sustained the weight of two feet of intes- 
tine. From eight to ten inches below this intussusception there was another, 
which was immediately drawn out the moment the intestine was disturbed. The 
other abdominal viscera were healthy. 

There is uncertainty as to the duration of the intussusception in the above 
case, but the symptoms indicated that it existed a considerable time prior to 
death. There was no strangulation, nor indeed any appreciable anatomical 
alteration in the coats of the intestine, but the fact that the invaginated mass 
sustained two feet of intestine and required considerable traction for its reduc- 
tion shows that it was not a case of simple displacement occurring at the 
moment of death and without symptoms, but was an example of the variety 
with symptoms. 

Intussusception in the Large Intestines. 

In most cases of intussusception occurring in infancy and childhood the 
ileum is invaginated in the colon or the first part of the colon is invaginated 
in the part succeeding it. Intussusception not infrequently begins in the 
prolapse of the ileum through the ileo-cgecal valve, in the same way that pro- 
lapse of the rectum occurs through the sphincter ani. If death take place 
early, only a small portion of the ileum may have passed the valve. If the 
case be protracted, the tenesmus brings down more and more of the ileum, 
with its accompanying mesentery. The constriction of the valve, which acts 
as a ligature, soon prevents the further descent of the ileum ; and, the tenes- 
mus continuing, the next step in the displacement is the inversion of the 
caput coli, which is drawn into the colon by the descending mass, and unless 
the case terminate by sloughing or death, the ascending and transverse por- 
tions of the colon are successively invaginated. The records show that 



iSTUSsrscEPTioy ly the large lyiESTixEs. 843 

intussusception occurs as above stated in a large proportion of cases. In one 
case among those which I have collated the invagination began a few inches 
above the valve, so that the ileum constituted a small portion of the exterior 
of the mass. Occasionally the caecum is the part primarily inverted and 
invaginated, and, descending along the colon, it draws after it the ileum, 
which sustains its natural relation to the ileo-caecal valve. When this occurs 
the caecum is found at the lower end of the mass, and two orifices are 
observed, one leading through the valve and the other into the appendix ver- 
miformis. These two forms of invagination — that in which the ileum, passing- 
through the ileo-caecal valve, successively inverts and draws after it the caput 
coli and the divisions of the colon, and that in which the caput coli is pri- 
marily invaginated, and, descending along the large intestine, inverts the lat- 
ter and draws after it the ileum — constitute the vast majority of cases of this 
disease in the first years of life. 

I have notes of -45 fatal cases occurring under the age of twelve years in 
w^hich the portion of intestine first displaced is recorded. In four of these 
the displacement was entirely in the small intestine, involving in no way the 
<3olon ; in 38 cases it commenced either by prolapse of the ileum through the 
ileo-csecal valve or by the inversion of the c^cum into the ascending colon, 
there being perhaps not much difi*erence in the relative frequency of these 
two modes ; in one case the invagination was confined to a segment of the trans- 
verse colon, in another to a segment of the descending colon, and in the 
remaining case to the lower part of the descending colon and the upper part 
of the rectum. In three instances the invaginated mass itself became invag- 
inated, producing an intussusception of great thickness, and necessarily 
fatal. 

Intussusception is sometimes attended by so little constriction of the incar- 
cerated portion that it remains pervious. In such a case life may be pro- 
tracted for weeks or even months without reduction of the displacement or 
any material change in it, the passage of fecal matter being sufficiently free 
for the maintenance of life. Death finally occurs in a state of exhaustion. 
Thus in one instance a child four months old lived six weeks after the symp- 
toms of invagination commenced, and seventeen days " with a portion of the 
bowel protruding from the anus." It was found at the post-mortem exami- 
nation that part of the ileum had descended through the entire colon, and 
had remained pervious. In a case related by Dr. Worthington ^ symptoms 
of intussusception were present for seven months before death, and during 
the last six weeks of life the invaginated intestine protruded frequently from 
the anus, and was replaced by the mother. In this case '• the caecum was 
inverted, and, descending through the colon to the lower portion of the rec- 
tum, carried with it the ileum and the entire colon except the last ten or 
twelve inches." In another case the symptoms indicated a continuance of 
the disease for three, if not eight, months. But such cases are exceptional. 
Ordinarily, as the intestine becomes invaginated its mesentery or meso-colon 
is also invaginated and its veins compressed. The pathological state of the 
incarcerated mass soon becomes that of intense congestion. In infants, 
usually in a few hours, so great is the distension of the capillaries that they 
give way, blood escapes into the intestine, and passes from the bowels in 
scanty motions. On examining the invaginated intestine after death, if gan- 
grene have not occurred, it is found of a uniformly intense red color, some- 
times resembling to the naked eye a long and firm clot of blood. In those 
who die early no traces of inflammation are seen, but in more protracted cases 
the attrition between the serous surfaces excites local peritonitis. In none of 
the fifty-two cases which I have collated in which post-mortem examinations 

^ Amer. Jour, of Med. Sci., for January, 1849. 



844 INTUSSUSCEPTION. 

were made did the inflammation extend more than a few lines beyond the 
invagination. Usually the intestine forming the exterior of the invaginated 
mass is much drawn together or puckered. In one case treated by myself 
the entire large intestine which formed the exterior of the mass was com- 
pressed within a space of six inches or less, since about twelve inches of the 
ileum, doubled on itself, lay within the entire colon and protruded from the 
anus, the only part of the large intestine which was inverted being the caput 
coli. In one case six or seven inches of the ileum, which formed a portion of 
the exterior of the mass, were compressed within the space of one inch. 

The abdomen, at first of natural fulness and soft, usually becomes more 
and more distended till the close of life ; but in cases of much vomiting the 
distension is moderate. This fulness is due to gas and fecal accumulation 
above the invagination. The portion of the intestine below the displacement 
is ordinarily empty, except that in the infant it commonly contains mucus, 
mixed with more or less blood which has escaped from the capillaries of the 
strangulated mass. 

There are few anatomical changes in this disease which do not arise 
directly from the intussusception, and are therefore located either within the 
mass or in its immediate vicinity. In those who recover by the process of 
sloughing the cicatricial contraction may give rise to symptoms and lesions of 
greater or less gravity. Thus the late Sir James Y. Simpson examined a 
child aged nine years who recovered with loss of ten inches of intestine, and, 
at the meeting of the Medical Society ^ before which the specimen was pre- 
sented, he remarked that there was unusual distension of the cutaneous veins 
of the patient, due probably to such compressions of the ascending vena cava 
by the cicatrix that the venous circulation was obstructed. Mr. Charles 
King- relates the case of a child aged six years who on the eleventh day of 
the disease voided the caecum and a part of the colon. Two days subse- 
quently pulsation ceased in the left leg, and all that part below the patella 
became gangrenous. The patient gradually recovered with loss of the leg. 
The cause of this unfortunate sequel was doubtless compression from the 
cicatricial contraction around the artery which supplied the leg, and probably 
the formation of a thrombus. Dr. F. Bush^ relates a case in which he was 
enabled to observe the extent and appearance of the cicatrix. The patient, 
aged twelve years, discharged from the bowels fifteen to eighteen inches of 
the ileum on the eighth day of the intussusception, after which convalescence 
was rapid. Fourteen weeks later the child died from typhus fever, and at the 
autopsy " traces of the diseased bowels were visible by a contraction and 
puckering where the slough had taken place and the parts united." But,, 
fortunately, in most instances when the intestine sloughs and the child 
survives, no serious or permanent injury results from the cicatrization. The 
cicatrix stretches little by little and accommodates itself to the surrounding 
parts. 

Symptoms. — The symptoms vary according to the age of the patient and 
the degree of strangulation. Pain in the abdomen, usually paroxysmal, is 
among the first and is one of the most conspicuous symptoms. It is often 
severe, resembling the pain of hernia, and abating only with the failing 
strength of the child. After the first few days, if inflammation arise, the 
pain is continuous, though more severe in paroxysms. At first pressure upon 
the abdomen is tolerated, but afterward there is tenderness. This is due to 
the inflammation which occurs in and around the invaginated mass, and it is 
therefore confined to the part of the abdomen in which the tumor lies. At 
this point also the abdomen is more full than elsewhere, and not infrequently 

^ Trans. 3Iedico-Chir. Soc. Ed in. ^ London Lancet^ for 1854. 

^ Lond. Med. and Phys. Jour., for December 18, 1823. 



INTUSSUSCEPTTOy IX THE LARGE INTESTINES. 845 

the phj^sician can feel the invaginated mass and detect its exact location and 
approximately its extent. Sometimes, at an early period as well as late, 
cerebral symptoms occur, as in a case related by Dr. Coggswell,^ which ter- 
minated in convulsions and death on the second day. Convulsions are, how- 
ever, comparatively rare, and the mind is generally clear till the last moment. 
In infants the countenance in the intervals of pain, in the first stages of the 
complaint, is often placid, and not indicative of any serious disease, but in 
older patients constant and severe local symptoms, referable to the intus- 
susception, commence early. At an advanced period, whatever the age, the 
countenance becomes anxious and haggard, the eyes hollow or sunken, the 
body loses its plumpness, and, if the case be protracted, becomes emaciated. 

Vomiting is rarely absent ; in 39 out of 47 cases it is stated to have been 
present, in 7 cases there is no record of this symptom, while it is recorded 
absent in only 1 case ; but in this case, the records of which are very meagre, 
death occurred on the second day. The vomiting becomes -stercoraceous in a 
few days, and it ordinarily continues with greater or less frequency till the 
period of collapse. It relieves partially the distension. 

The appetite is impaired and often entirely lost. Infants at the breast 
commonly nurse, however, for several days, probably from thirst rather than 
hunger. 

In most patients one natural evacuation occurs from the bowels after the 
intussusception commences, and then obstinate constipation succeeds. This 
evacuation consists of the excrementitious matter below the invagination. 
In children under the age of one year scanty motions of blood mixed with 
mucus begin to occur in a few hours. Of 27 children under this age, I find 
that 24 had such evacuations, occurring in most of them several times in the 
course of the day ; in 2 of the 27 there is no record of this symptom, but in 
the remaining case it is stated to have been absent. Scanty evacuations of 
blood unmixed with fecal matter have been considered pathognomonic of 
intussusception in the infant, and we see the ground for such belief ; but in 
exceptional instances the invaginated mass is partly pervious, and although 
the dejections may contain blood they are also excrementitious. In our col- 
lection of cases are 3 examples of this in infants under the age of one year. 
One has already been referred to. In this case there was the rare anomaly of 
so large an opening through the ileo-caecal valve as to allow not only prolapse 
and descent of the ileum through the entire colon, so as to protrude six inches 
from the anus, but also fecal passage through it daily. 

In children above the age of one year the capillaries of the invaginated 
intestines are not so frequently ruptured as under this age, and sanguineous 
evacuations are therefore less common. I have records of 19 cases between 
the age of one year and twelve, in only 6 of which it is stated that there were 
bloody motions, and in these the blood was not passed frequently, nor even 
in some cases daily, as in infants, nor in so pure a state, unless in 2 cases, 
the records of which are not explicit on this point. Two of these 6 patients 
passed moderate bloody evacuations after protracted periods of constipation, 
one had fecal discharges with the blood through the entire sickness, and in 
one blood was passed at first, but finally the stools were entirely fecal. 

In those above the age of one year obstinate constipation was ordinarily 
present, no dejections, either bloody or fecal, occurring for several days ; but 
there were a few exceptions. In 3 cases the bowels were relaxed. The 
ileum in these 3 had descended through the entire colon or the larger part 
of the colon, and, being pervious, the feces escaped from the anus without 
detention in the large intestine or with detention only in its lower portion, 
and were therefore liquid. 

' London Lancet, for July, 1853. 



846 INTUSSUSCEPTION. 

Tenesmus is another symptom. It is not always present, but in a large 
proportion of cases, even when the invagination is in the upper part of the 
large intestine, it is a frequent and distressing symptom. It often does not 
commence till there is a considerable amount of displacement, and it ceases 
when the strength is much reduced. 

The temperature of the surface is normal in the commencement of intus- 
susception ; but finally, as febrile reaction symptomatic of the inflammation 
comes on, it rises and continues above the healthy standard till the intestine 
sloughs or till the stage of collapse occurs which ushers in death. The pulse, 
especially in the infant, is tranquil at first, but, whatever the age, it soon 
becomes accelerated from the paroxysms of pain, and subsequently from the 
inflammation which occurs in the invaginated mass. There is no disturbance 
of respiration, except that it is somewhat hurried from the fever and from 
the pain felt in advanced cases on full inspiration. 

It will be seen that the symptoms vary in certain particulars under the 
age of one year from those occurring over that age, but diff"erences in the 
symptoms depend more on the degree of invagination and constriction than 
on the age and exact location of the disease. 

Diagnosis. — The diagnosis of intussusception is not, in general, difficult, 
except at its commencement. When the inversion has reached that degree 
at which obstruction occurs, the symptoms are, in most cases, such that the 
disease can be readily diagnosticated. In the cases whose records I have col- 
lated a correct diagnosis was made with few exceptions, and at an early period. 
In the infant the disease for which intussusception is most frequently mis- 
taken is dysentery, on account of the tenesmus and the muco-sanguineous 
stools. In certain of the reported cases this mistake was not rectified until 
it was ascertained that purgatives produced no fecal evacuations. 

The symptoms which are commonly present, and which indicate the 
nature of the disease, are obstinate constipation, vomiting, paroxysmal pain 
referred to the seat of the disease, and tenesmus. In the infant also scanty 
evacuations from the bowels of mucus and blood or of pure blood are, as we 
have seen, an important diagnostic sign. It should be borne in mind, how- 
ever, that in exceptional cases the displaced bowel may remain pervious, and 
the usual symptoms which possess diagnostic value therefore be absent. 
There may be no vomiting or tenesmus, and diarrhoea may even occur in place 
of constipation, as in the cases related above. As an aid to diagnosis it 
should he stated that, whatever the age of the child aff"ected with intussus- 
ception, clysters are often administered with difficulty, and are quickly and 
forcibly returned, on account of the resistance opposed by the invaginated 
mass. We have stated above that the seat and even extent of displacement 
can be ascertained in a large proportion of cases by digital examination of 
the abdominal walls. The tumor can be felt hard, enlongated, and tender on 
pressure, so that the diagnosis is clear. If the invagination have extended 
to the lower part of the large intestine, it can usually be discovered by an 
examination per rectum. 

Duration. — In the following table the duration of the intussusception 
in 49 cases is given as nearly as it can be ascertained from the records :. 

1 died the 8th day. 

1 " " 10th " 

1 " " 14th " 

1 lived nearly a week, the exact 

time not being given. 
1 lived six weeks. 
3, time of death not given. 
7 recovered. 



2 died the 1st day. i 


6 " 


" 2d " 


14 " 


" 3d " 


2 " 


" 4th " 


5 " 


" 5th " 


2 " 


" 6th " 


2 " 


" 7th " 


1 lived 


over a week. 



INTUSSUSCEPTION IN THE LARGE INTESTINES. 847 

In 2 of the 3 cases in which the duration is not stated the patient lived much 
longer than the usual period. One of these 2, a girl of six years, having 
eaten raw carrots, was seized with pain in the abdomen, which lasted eight 
months, when she died. During the last three months she passed mucus 
and blood. In this case the cascum had descended to the anus, drawing with 
it the ileum, which remained pervious. The symptoms indicated the con- 
tinuance of the invagination for three months, if not eight. The other 
patient was a boy aged three years and four months, who complained of pain 
in the abdomen for many months, and occasionally vomited. During the last 
six weeks of his life all the phenomena of invagination were present. In 
this case also the inverted caput coli had descended the entire length of the 
colon, and at the autopsy it lay in the rectum. 

In AVest's Treatise on Diseases of Children (5th ed., 1866, p. 504) it is 
stated that death in this complaint always occurs within a week. The above 
statistics, however, show that there are exceptions to this statement, although 
a large majority do die within the first seven days. In 33 of the cases 
embraced in my statistics death occurred within the first week, and in no 
fatal case in which strangulation was complete was life prolonged beyond the 
eighth day. In these cases of complete strangulation the average duration 
was 3.7 days, and the largest number of deaths occurred on the third day. 
Death on the first day is rare, but it occurred in two of the cases embraced 
in my statistics. Death at so early a period usually takes place in convul- 
sions and coma. 

Prognosis. — Intussusception is in its nature so grave an accident that the 
physician called to a case should always explain its gravity to the friends. 
But, while death is the common result, there are three different modes of 
termination in which life is preserved : First, the reduction of the incarcerated 
intestine, with immediate relief. There can be no doubt that it is possible for 
intussusception, when recent, to be reduced by the unaided action of the 
bowels, in the same way as the common, simple intussusception in the 
jejunum and ileum or as hernia is reduced, through the vermicular action 
of the intestines; for sometimes, as in Dr. Coggswell's^ case, the patients at 
some previous time have experienced the same symptoms as those which 
accompanied the attack, and which subsiding they remained for a time in 
perfect health. This termination is probably rare if the symptoms be 
sufficiently marked to necessitate treatment. Again, the intussusception may 
be cured by early and well-applied treatment. The physician often succeeds 
in reducing the displaced intestine, even if the intussusception be in the 
upper part of the colon, if he be called sufiiciently early and employ the 
proper measures. 

A second mode of favorable termination is alluded to by certain foreign 
writers. The intussusception continues for a considerable period with the cha- 
racteristic symptoms, and then, as Bouchut expresses it, " the vomitings grad- 
ually cease, the intestinal hemorrhage disappears, the strength returns, and 
the health becomes restored without the expulsion of fragments of the intes- 
tine." What changes the displaced intestine undergoes in these protracted 
cases, which gradually recover without sloughing, have not been clearly ascer- 
tained, although they have been the subject of conjecture. According to 
Rilliet, a large proportion of favorable cases terminate in this manner. It 
does not appear, however, from the statistics which I have collected that this 
is a common mode of recovery. The clinical history of intussusception estab- 
lishes the fact that in a large majority of protracted cases there is either death 
or the third mode of favorable termination — namely, by sloughing. 

But we cannot reasonably expect recovery in young children through 

^ London Lancet, July, 1853. 



848 INTUSSUSCEPTION. 

sloughing and the expulsion of the intestine, since few have the requisite 
strength for so tedious and exhaustive a process. The youngest child that 
recovered in this way, so far as I have been able to ascertain, was an infant 
thirteen months old, whose case was reported by M. Marage. With the 
exception of this case the youngest was a boy aged five years. The older 
the child the greater, of course, the power of endurance and the better the 
prospect of recovery. Of the 52 cases whose records I have collated, 7 
recovered by the sloughing and expulsion of the mass. These children were 
of the ages of five, six, six, nine, eleven, twelve, and twelve years. The sep- 
aration of the invaginated mass occurred in six of these between the sixth 
and twelfth days, with an average of nine and a half days. In the remain- 
ing case the time is not given. If, then, the patient can be carried through 
the first week without too much exhaustion, discharge of the slough, reopen- 
ing of the bowels, and ultimate recovery may possibly be the result. 

But in those cases in which the intussusception remains open, so as to 
allow the passage of fecal matter, recovery is improbable unless the displace- 
ment be diagnosticated early and properly treated. If the intussusception 
continue, it becomes greater and greater from the absence of strangulation. 
Without inflammation and with little or no congestion of the displaced por- 
tion, and without the severe symptoms which occur in ordinary cases, the 
patient wastes away, having irregular evacuations and more or less abdominal 
pain, and finally dies in a state of emaciation and weakness. In the early 
stage of this form of displacement it is not improbable that injections or 
inflation, employed with sufficient force, will give relief, but if the early 
period pass without such treatment cure is impossible by the ordinary 
methods. It is in such instances especially — to wit, those in which the 
displacement occurs without strangulation or inflammation, and in which 
fecal matter passes through the displaced mass more or less freely — that 
laparotomy is justifiable, and is likely to give relief when injections and 
inflation have been employed in vain. Jonathan Hutchinson's successful 
performance of this operation in a child of two years who had this kind of 
displacement is known to most readers.^ 

The prognosis is most favorable when the displacement occurs in the 
lower part of the large intestine, for its reduction is then comparatively easy. 
An interesting case of this kind was observed and treated by Drs. O'Dwyer, 
Reid, and myself in the New York Foundling Asylum in 1875. The child 
was a female aged two years, and had had previous good health. The 
invaginated mass protruded like a prolapse about four inches outside of the 
anus. It was cold, considerable hemorrhage had occurred from it, and the 
infant seemed in collapse. When the mass was returned so far as it could 
be carried within the pelvis by the index finger, the lower end of it could 
still be felt like an os uteri. It protruded four or five times within twenty- 
four hours, but by replacement so far as possible with the fingers and the use 
of simple water injections, with the hips elevated, it was finally permanently 
reduced, and, with the use of stimulants, she soon fully recovered. 

Mode of Death. — This is difl"erent in diff"erent cases. It sometimes 
occurs from collapse. At a meeting of the New York Pathological Society, 
held December 10, 1873, I presented a specimen, showing intussusception 
occurring about one foot above the ileo-caecal valve in an infant aged thirteen 
months. On the day before its death, its previous health having been good, 
it seemed ill, and vomited once or twice, but did not appear to be in pain. It 
had two evacuations from the bowels, of the usual appearance, in the latter 
part of the day. On the following morning it was unexpectedly in collapse, 
and died within about twenty-four hours from the commencement of the sick- 
^ London Lancet, November 22, 1873. 



ISTUSSUSCEPTIOy IX THE LARGE INTESTINES. 849 

ness. At the post-mortem examination the cranium was not opened, but all 
the organs of the trunk were found normal except the intussusception. The 
mass involved in the displacement measured two and a half inches in length 
and was slightly crescentic. The mucous membrane above and below it had 
the normal appearance, as had that of the external or incarcerating portion of 
the mass, while that of the incarcerated part was deeply injected. Water 
poured into the intestine above the invagination was wholly arrested by it.^ 
But in the majority of instances death occurs from asthenia, which comes on 
gradually, but increases rapidly in consequence of the pain, vomiting, and 
imperfect nutrition. Children dying in this way may have convulsive 
movements more or less marked, but the prevailing characteristic as death 
approaches is extreme exhaustion. In exceptional instances the life of the 
sufferer is cut short by convulsions before the stage of exhaustion is reached. 
Thus a child aged three years, whose case was reported by Dr. Isaac Thomas,'^ 
and another, aged two years, whose case was reported by Dr. Coggswell.^ died 
in convulsions on the second da}'. 

Treatment. — It is unfortunate in cases of intussusception that the time 
in which treatment can be of most service is likely to pass' by before the true 
condition of the intestine is detected. Invagination being comparatively rare, 
the patient is generally on the first day treated for colic or dysentery or some 
other common affection of the bowels ; and it is often not till the second day, 
when the intestine has become incarcerated, that the physician accurately diag- 
nosticates the disease. The purgative medicines often given in the commence- 
ment injure the patient. In fact, both reason and experience teach us the 
impropriety of using purgatives in this complaint. Cathartic remedies act as 
a vis a tergo. and ma}' cause still further descent of the inverted intestine. 
Yet such powerful agents of this class as quicksilver have been employed. 
It was administered in two doses of one ounce each in one of the cases 
embraced in my statistics, but none of the mineral passed the bowels. At 
the post-mortem examination a considerable part of it was found in small 
globules, coated with a black layer consisting of the sulphuret or black oxide 
of mercury, in the intestine above the intussusception. It need not be added 
that the case was speedily fatal. 

The proper treatment of intussusception consists in attempts to reduce 
the displacement by pressure from below. The pressure may be applied 
•either by liquid injections into the rectum or by inflation of the lower intes- 
tine by air or gas. 

Injections should be made with lukewarm water, for cold or hot water 
may cause contraction of the muscular fibres of the intestine and increase 
the constriction. The child should be placed in bed or in the nurse's lap, 
with the nates elevated 45°. With the common India-rubber — or, better, 
the fountain-syringe — and the aid of an assistant the liquid should be gently 
thrown into the rectum until the abdomen is fully distended. By carry- 
ing the fingers, firmly but gently applied upon the abdominal walls, along the 
direction of the colon, the liquid is made to press against the lower end of 
the intussusception. The same gentleness and perseverance are required in 
kneading and pressing the abdominal walls as in the treatment of hernia by 
taxis. If the invagination be in the descending colon, probably only a small 
quantity of the liquid can be injected, and it may be forcibly returned, but 
by repeating the injections a sufficient quantity can ordinarily be introduced 
to obtain the full effect of the mode of treatment. There is also sometimes 
an increased irritability of the rectum, even when the intussusception is at 
the upper extremity of the large intestine, so that tenesmus and expulsive 

^ Nev: York Medical Record, April 1, 1874. ^ ^,,,g,, j^g^_ Recorder, 1823. 

^ London Lancet, July, 1853. 
54 



850 INTUSSUSCEPTION. 

efforts follow the introduction of the instrument. The assistant can aid in 
overcoming this and in retaining the water by pressing the soft parts of the 
nates around the instrument. 

If the injection fail to reduce the displacement, it may be repeated after 
allowing the patient to rest for a while. In the New York Medical Journal 
for May, 1875, is the history of an interesting case which was treated by Drs. 
Church and Warren of this city, and is reported by the latter. The infant 
was seven months old and had the usual symptoms, such as frequent parox- 
ysmal pain in the abdomen, vomiting, tenesmus, scanty muco-sanguineous 
stools. On the third day injections were twice employed without result, but 
on the fourth day an injection of ten or twelve ounces reduced the displace- 
ment and the infant recovered. In a second case treated by Dr. Warren the 
age was nine months, and a tumor appeared a little above the umbilicus a few 
hours after the commencement of the symptoms. The following is Dr. War- 
ren's account of this interesting case, which will give a clear idea of the proper 
mode of treatment : 

" The patient was looking very pale and prostrated, the pulse was quick 
and feeble, and the skin cold. I at once determined to use fluid injections, 
and, with the little patient placed in a semi-prone position in his mother's lap, 
with an ordinary Davidson's syringe I commenced injecting tepid soap and 
water, but after perhaps a gill had been thrown into the rectum it was almost 
immediately rejected, very highly colored with blood, and mixed with it a very 
small quantity of mucus and fecal matter ; the latter, by the way, not hard- 
ened, but of the consistency of soft putty. In a second attempt the fluid 
was retained longer, but was after a little while discharged, with more blood 
and mucus, but with much less tenesmus and pain. 

"When, soon after, I made my third attempt, the child's chest was rested 
upon the side of its mother's lap, with the lower extremities elevated by an 
assistant, so that the position was at an angle of about 45°, anus upward. 
This time I injected the fluid very slowly, in order to avoid, if possible, the 
irritation caused generally by the frequent emptying and refilling of the 
syringe (which, by the way, is a very serious hindrance to the successful use 
of this syringe, and which renders it much inferior to the fountain or hydro- 
static). In this manner I succeeded in injecting, as I estimated at the time, 
perhaps ten or twelve ounces, and during the operation the child gradually 
became more quiet, and had, when I ceased, fallen asleep. Then, with the 
direction that occasional doses of tinct. opii camph. should be administered 
during the night, to control, if possible, the peristaltic action of the intes- 
tines, I left him. 

" On the following morning, to my surprise, I found the child sleeping 
quietly and naturally, and I was informed that at about 5 A. m. (six hours 
after my visit) he had a movement of the bowels, which was saved for my 
inspection, and consisted simply of the enema, slightly colored with fecal 
matter. From that time he seemed to be entirely free from pain, and six or 
seven hours later had a natural passage, after which recovery progressed 
rapidly, and in a few days he was discharged well." 

The following case is interesting as showing success from the use of 
injections after the lapse of two days in a severe case which had resisted 
treatment on the first day. The good result was apparently in great part due 
to the manipulation, which was made so as to press the water against the 
course which intussusceptions are known to take. 

On September 10, 1876, I visited, with Dr. Gillette, a nursing infant aged 
nine months whose history was as follows : It was habitually constipated, but 
it continued in its usual health till September 8th, on which day it was carried 
by its nurse to one of the city parks. After its return it began to be fretful ; 



INTUSSUSCEPTION IN THE LARGE INTESTINES. 851 

it vomited and seemed to be in pain. It continued to vomit frequently, espe- 
cially after nursing or taking drinks, and in the ensuing night passed two 
scanty stools of mucus and blood without fecal matter. In the morning of 
September 9th, Dr. G. was summoned, who found the pulse 180 and tem- 
perature 102°, and the matter vomited greenish like bile. In the evening the 
temperature was 102f °. Dr. G. diagnosticated intussusception, and employed 
injections of water, but they were returned without bringing fecal matter and 
without apparent result. He also administered opiates by the mouth. 

September 10th, temperature 102f ° ; features pallid, beginning to have a 
pinched or sunken appearance, and indicative of much suffering; no nutri- 
ment is' apparently retained, on account of the frequent vomiting, and the 
bowels are obstinately constipated. As the symptoms indicated rapid sink- 
ing and collapse, consultation was called at 4 p. m. It was impossible to 
determine certainly, through the abdominal walls, on account of the disten- 
sion, whether there was any tumor, but it was my opinion and the opinion of 
one of the other physicians that a tumor, hard and inelastic, could be felt 
nearly in the median line between the umbilicus and the symphysis pubis. 
At about 5 P. M. the shoulders of the little patient were lowered and the 
nates elevated, so that the trunk formed an angle of perhaps 45° with the 
horizontal, and a large quantity of tepid water was gently passed into the 
intestine through Davidson's syringe, with the vaginal nozzle attached. It 
was impossible to estimate the quantity retained, since a considerable part of 
it escaped, although the anus was firmly pressed around the instrument. 

When the abdomen was distended as fully as seemed justifiable, the nates 
being still elevated, and the liquid retained, so far as possible, by firm pres- 
sure upon the anus, the abdomen was firmly and deeply kneaded by the 
hand, the movements being made chiefly from the right lumbar toward the 
right inguinal, and from the right inguinal toward the hypogastric region. 
The kneading was continued perhaps eight or ten minutes, and the water, 
which contained no perceptible amount of fecal matter, blood, or mucus, was 
allowed to escape. 

After this operation the child became quiet, slept, and the vomiting 
ceased. At our next visit, at 7 P. m., although the severe symptoms had 
in a great part abated and the countenance had lost that pinched and suffer- 
ing aspect which was so prominent before, it was deemed best, in consulta- 
tion, to repeat the injection, and this time through a rectal tube, which was 
introduced farther than the nozzle employed at the preceding visit. The 
body was placed in the same position as before and the abdomen kneaded in 
the same manner. The water, when allowed to return, brought no fecal mat- 
ter, but the last that flowed contained two shreds, the largest about one inch 
in length by two lines in width, resembling matted and nucleated epithelial 
cells. It was believed that they were composed of such cells, with perhaps 
some of the mucous membrane to which they were attached, and that they 
were detached from the invaginated portion. An opiate mixture was now 
prescribed, to be given sufficiently often to relieve any restlessness and keep 
the patient quiet, and a flaxseed poultice was applied over the abdomen. 
On the following day the temperature was 103^°, pulse 158, and the abdo- 
men somewhat distended ; but the vomiting had ceased and there had been 
two fecal evacuations since our last visit. The intussusception had been 
relieved, the inflammatory symptoms soon abated, and the infant's health was 
fully restored. 

Groodhart reports a case of cure by injecting a boracic-acid solution after 
the symptoms had continued seventy-six hours. The patient's age was eight 
months, and the tumor could be felt per rectum.^ Humphreys relates two 
1 Londo7i Lancet, Feb. 25, 1888. 



852 INTUSSUSCEPTION. 

cases of recovery by injection of water thirteen and forty hours after the 
commencement of symptoms in infants of eight months and two years/ 
Butler also succeeded by water injections in reducing intussusception of 
thirty-six hours' continuance in a child of three years. -^ But injections of 
water have not always been successful. Chaffey failed to reduce invagination 
of the csecum and appendix in a " somewhat chronic " case, but inflammatory 
bands were found in their vicinity,^ and Cripps ruptured the intestine by 
injecting water in a girl of eighteen months. The symptoms had continued 
four or five days, and the tumor projected from the anus. 

Injections, in order to be effectual and give promise of success, should be 
aided by gravitation. The physician should remember to elevate the nates 
higher than the shoulders, as in the case related above. Treatment by infla- 
tion — which indeed ought to occur to any intelligent physician appreciating 
the anatomical condition of the parts as deserving of trial — was prominently 
brought to the notice of the profession in modern times by Mr. Samuel 
Mitchell.* " I take the liberty," he writes, '' of suggesting to the profession, 
through the medium of your valuable periodical, the trial of inflating the 
bowels by means of a glyster-pipe attached to a common pair of bellows ; it 
has fallen to my lot to witness several of these most distressing cases in chil- 
dren ; the nature of the obstruction was foretold during life, and unfortu- 
nately verified by post-mortem examination. The last case of the kind which 
came under my care, about two years since, presented all the usual symp- 
toms — intolerable restlessness, the most obstinate sickness, the singularly dis- 
tressed state of countenance, and shrunken features. The usual remedies 
were had recourse to — viz. warm baths, glysters, anodyne frictions over the 
abdomen, etc. — but without avail. As a forlorn hope I made trial of infla- 
tion by the above means, with the most happy result. The sickness imme- 
diately ceased ; the child within an hour passed a natural stool, and in the 
morning was almost without ailment." 

This mode of treatment is termed novel in the Lancet, but it is really as 
old as the time of Hippocrates, who speaks of throwing air into the bowels, 
by which flatulence is imitated (flatus immitatur).^ Haller® also recom- 
mended the same treatment : " Flatus etiam immissus celerrime susceptionem 
dispellet." Dr. David Greig ' relates five cases of successful treatment of 
intussusception by inflation. The first, an infant six months old, previously 
in good health, suddenly became very fretful, apparently having severe 
paroxysmal pain in the abdomen. She had vomiting, and finally tenesmus, 
with bloody evacuations. Warm-water enemata could not be employed, on 
account, the writer thinks, of the spasmodic action of the intestines, and an 
abdominal tumor could be felt near the umbilicus. Castor oil and a purga- 
tive powder and enemata of water having been employed in vain, and the 
case becoming really critical on the second day, inflation was resorted to. 
The writer says : " The nozzle of a small pair of bellows was introduced into 
the anus, and air injected to a considerable extent. Contrary to our expecta- 
tion, the air passed readily into the bowel, and seemed to give the child great 
relief. After the injection it lay very quiet, as if asleep, and evidently quite 
free from pain. In about twenty minutes from the time the air injection was 
administered a slight rumbling noise was heard in the child's abdomen, fol- 
lowed by a crack so loud and distinct as to alarm the attendants in the room, 
who thought something had burst in the child's bowels. The child, however, 

^ London Lancet, Oct. 27, 1888. ^ Brooklyn Med. Jour., Feb., 1888. 

3 London Lancet, July 7, 1888. * Ibid., for March 17, 1838. 

^ Hippocrates' Works, translated from the Greek by Grimm, 4 Bd., p. 198. 

* Fhysiologia Corporis Humani, tom. vii. p. 95. 

^ Edinburgh Medical Journal, October, 1864. 



INTUSSUSCEPTION IN THE LARGE INTESTINES. 853 

continued as if asleep and free from pain, and in about half an hour a large 
feculent stool, slightly mixed with blood and mucus, was passed without pain. 
During the night the child rested pretty well, had no return of vomiting, took 
the breast as usual, and in two days was quite well." 

Another child, nine months old, treated by Dr. Greig, presenting nearly 
the same symptoms and the abdominal tumor, also obtained relief by inflation 
after castor oil and enemata had failed to produce any benefit. 

An apparatus for the production and injection of carbonic-acid gas has 
been invented by Schultz & Warker of this city, and is manufactured by 
them. It consists essentially of two glass chambers, one over the other. In 
the lower one a bicarbonate is placed, and in the upper an acid in a liquid 
state. By the gradual admixture of the two, carbonic acid is set free. An 
elastic tube conveys the gas from the lower chamber. This apparatus has 
been used by physicians of this city for the reduction of intussusception and 
other purposes, and is a useful invention. 

The same firm and several others in this city prepare for the shops large 
bottles of highly-charged carbonic-acid water, from which, when inverted, 
a powerful current of the gas can be obtained. Two or three of these bot- 
tles, with a portion of the tube from Davidson's syringe, which can be readily 
attached to the stem from which the gas escapes, constitute all that is required 
for an ordinary case. 

The following cases, which I have treated with Dr. Biichler of this city in 
1871, show what may be achieved by inflation, and also the unfavorable 
result which must inevitably occur in certain cases. A German infant five 
months old, nursing, began to be fretful, crying often, on March 7th, and 
before night passed a scanty motion of blood. The symptoms continuing, I 
was asked to examine the infant on the lOth^ and learned the following facts : 
It had vomited daily, had had daily scanty but infrequent stools, consisting 
chiefly of blood, accompanied at first by tenesmus, but not within the last 
day ; it continued to nurse, but was becoming thinner and weaker, and was 
evidently in pain. The symptoms indicating the nature of the disease, the 
abdomen, which was not distended, was examined for the tumor, which was 
found in the right side in the site of the ascending colon, apparently about 
one and a half to two inches in length ; pulse 124 in sleep ; no cough. An 
ineffectual attempt was made to reduce the intussusception by a very rude 
and imperfectly constructed apparatus (the bellows), when from the lateness 
of the hour further treatment was postponed till early the following morning. 
11th. Tumor still detected in the right lumbar region ; pulse 120 asleep, 
150 awake. By means of Schultz & Warker's apparatus the intestines were 
inflated so as to produce very decided prominence of the abdomen, and the 
abdomen gently kneaded. After some minutes the gas was allowed to escape, 
when the tumor had disappeared. In a few hours a natural evacuation 
occurred from the bowels, and the infant has remained well since. 

The second case ended unfavorably, although the symptoms were appar- 
ently no more grave than in the case just related and had continued a shorter 
time. This infant was also of German parentage. The tumor, firm and 
elongated, could be distinctly felt in the left lumbar region. In this case the 
inverted bottles of carbonic-acid water were employed, and when, after con- 
siderable delay and kneading of the abdomen, the gas was allowed to escape 
from the intestine, the tumor had disappeared. A few hours afterward con- 
vulsions occurred, ending fatally. At the autopsy the invaginated mass, 
which was too firmly strangulated to admit of reduction by inflation, was 
found in the epigastric region, having been carried up from its former posi- 
tion by the inflation of the intestine below. It consisted of the terminal 
part of the ileum, which had passed through the ileo-caecal orifice, and bad 



854 INTUSSUSCEPTION. 

become incarcerated in the ascending colon, and, as is not unusual in these 
cases, the movements of the intestines had changed the location of the tumor 
in the abdomen from the right to the left side. In the London Lancet for 
Feb. 18, 1888, Cheadle reports a case of successful inflation in an infant of 
fifteen months, whose symptoms indicated intussusception of fifteen hours' 
duration, and the tumor could be felt per rectum. Higginson also reduced 
an intussusception by inflation. The patient, an infant of seven months, had 
symptoms of intussception three days, and the tumor could also be felt per 
rectum.^ 

Whether air or carbonic acid be employed, it is necessary to produce dis- 
tension of the intestine to its fullest extent below the seat of the complaint 
without endangering rupture, and of course the sooner it is used the better 
the chance of success. In a few days the displaced intestine has, in a large 
proportion of cases, become so firmly incarcerated, and has descended so far, 
that attempts to replace it, either by injections or inflation, are unsuccessful ; 
still, even at a late period a persevering attempt should be made if it have 
not previously been tried. During the four years which have elapsed since 
the publication of the sixth edition of this treatise in 1886, I have treated 
successfully three — I think I may say four — cases of intussusception in infants 
by frequent rectal injections of warm water as large as could be given, and 
followed by kneading of the abdomen. The youngest of these infants was 

Geo. H. Mc , male, aged four months, nursing, to whom I was called on 

Dec. 24, 1886. He had been very fretful since Dec. 22d, had the last fecal 
evacuation on the morning of Dec. 23d, and had since passed stools of mucus 
and blood without the least fecal matter. Enemata of warm water as large 
as possible were given every hour to two hours with the nates raised, and 
were followed by kneading the abdomen. The fretfulness was always less 
after these enemata. On Dec. 26th the temperature fell from 101 J° to nor- 
mal, and a fecal evacuation, the first in three days, occurred. From this time 
the infant was well. The vomiting, which had been frequent since the 22d, 
ceased on the 26th. The mother stated that the tenesmus, which had been 
a distressing symptom, was uniformly less after the injections. My experi- 
ence during the last ten years with cases of intussusception incline me more 
and more to the belief that copious and frequent warm-water injections, 
employed in the manner described above, are more likely to give relief than 
any other mode of treatment. But it is proper that I should state that dur- 
ing this time I have seen cases that were fatal in which this and other modes 
of treatment, including laparotomy, were employed. 

If the modes of treatment which I have recommended above fail to give 
relief when perseveringly and sufiiciently employed in a case of acute intus- 
susception, the patient's state is one of extreme peril and the prognosis is 
unfavorable. Yet recovery is possible in one of two ways — namely, first, 
by incision through the abdominal walls (laparotomy), and reduction of the 
displacement by the fingers within the abdominal cavity ; and secondly, by 
sloughing of the invaginated mass and union by adhesive inflammation of 
the ends of the intestine which have preserved their vitality. Cripps relates 
a remarkable case of spontaneous cure in an infant of seven months. It had 
been two weeks sick, with vomiting and alvine discharges of blood and mucus, 
when presented for examination. A portion of the large intestine, gan- 
grenous, protruded from the rectum. This was cut off", and portions of 
sloughy substance were removed daily for a month afterward, when the child 
recovered. It died of scarlet fever eight months subsequently, and the 
autopsy revealed the entire loss of the large intestine, the small intestine 
being united to the anus.^ Atrophy of the imprisoned part so seldom occurs 

1 London Lancet, May 19, 1888. ' Brit. Med. Jour., June 2, 1888. 



INTUSSUSCEPTION IN THE LARGE INTESTINES. 855 

in a case which has resisted injections and inflation that it need not be con- 
sidered in this connection as a mode of recovery. 

Laparotomy has been successfully performed in a child aged two years, 
as T have stated above, by Dr. Jonathan Hutchinson of London. The case 
was one of those exceptional ones in which great displacement had occurred 
without strangulation. It had continued, as indicated by the symptoms, 
about one month, and a portion of the intestine terminating in the ileo-coecal 
valve had protruded several inches from the anus. '• The patient was anaes- 
thetized by chloroform, and the abdomen was opened in the middle line below 
the umbilicus. The intussusception was then easily found and as easily re- 
duced. The after-treatment consisted only in the administration of a few mild 
opiates, and the child made rapid recovery."^ In a case of this kind there 
can be no doubt of the propriety and necessity of laparotomy as the last 
resort, for, there being no strangulation, sloughing could not occur, and death 
sooner or later from exhaustion must be the result. Cases of this sort have 
usually been left to perish after the ordinary modes of relief have failed. 
Thus as far back as 1784, M. Robin published^ the case of a child aged 
three and a half years who died after the lapse of three months with a 
caecum protruding from the anus ; and in the American Journal of Medical 
Science for 1849, Dr. Worthington published a similar case, in which a child 
aged three years and four months lived a longer time. In these days of 
anaesthetics, and with the brilliant success of Hutchinson, a physician would, 
in my opinion, be reprehensible if he allowed a child aged two years or over 
with this form of displacement to perish without strongly advising laparotomy 
when injections with water have failed. 

But the question arises whether in those more frequent cases of intussus- 
ception in young children in which, after displacement has continued a few 
hours, there is such firm constriction of the invaginated mass that the patient 
sufiers much pain and constitutional disturbance, and passes blood and mucus 
without fecal matter, laparotomy is justifiable. This operation, in the case of 
infants, has heretofore been regarded as so dangerous and so likely in itself 
to prove fatal that the profession have generally considered it unjustifiable, 
believing that, although death was nearly certain without it, the perform- 
ance of it did not increase the chances of a favorable result. Dr. J. B. Sands 
of New York has recently shown that laparotomy is justifiable as a last resort 
for the relief of this form of intussusception, even in the youngest infants, 
and in the following case, recorded in the New York Medical Journal^ June, 
1877, saved the patient, who doubtless would otherwise have perished: 

On March 11, 1877, an infant of six months suddenly presented the cha- 
racteristic symptoms of intussusception, such as tenesmus, abdominal pain, 
vomiting, and bloody stools. A few hours later, when Dr. Sands was called, 
the pulse was rapid and feeble, with symptoms of collapse. An elongated 
tumor could be felt in the abdomen, extending from the left iliac region to 
the left hypochondrium, inelastic, tender on pressure, and dull on percussion. 
The lower end of the invaginated mass could be readily touched by the finger 
introduced into the rectum. The usual methods to eff"ect reduction were at 
once employed with partial success, for the tumor disappeared from the site 
where it had been discovered, and was reduced to a small and firm mass on 
a level with the umbilicus, but it resisted any further attempts to eff'ect its 
reduction. 

Dr. Sands then, having etherized the patient, made an incision in the 
median line of the abdomen, extending downward about two inches from a 
point a little below the umbilicus. Through this opening, proceeding cau- 
tiously and using as little violence as possible, he was able, after some delay, 

^ London Lancet, November 22, 1873. 2 j)/^,ji. ^/g V Acad, de Chirurg. 



856 APPENDICITIS, TYPHLITIS, PERITYPHLITIS. 

to reduce the displacement. The invaginated mass, which was only one and 
a half inches in length, consisted of the terminal portion of the ileum and 
caecum, which had entered the ascending colon. The wound was closed by 
five silver sutures, which embraced the peritoneum, and the patient made a 
good recovery. The operation was performed eighteen hours after the com- 
mencement of symptoms. 

Dr. Sands has collected the statistics of 20 cases of laparotomy for intus- 
susception occurring at different ages in which the result was stated. Of 
these, 7 recovered, or 1 in 3 ; but he judiciously remarks, considering the 
gravity of the operation, that it is doubtful whether future statistics will 
show so favorable a result of laparotomy for this displacement as to justify 
the frequent use of the knife. For facts and statistics relating to this sub- 
ject the reader is referred to an able and elaborate paper by Dr. Ashhurst.^ 

It is obvious that the earlier the displacement is recognized, the greater 
the probability of the reduction by the judicious use of injections or infla- 
tion, and it is seen from cases related above that this treatment may be suc- 
cessful as late as the second or third day, after previous attempts to reduce 
the intussusception by the same means have failed, and when there is that 
degree of strangulation that bloody stools occur. But, as my own expe- 
rience has shown me, there is also inevitably a large proportion of cases in 
which the use of injections and inflation, however judiciously and persever- 
ingly made, totally fail, and it seems to me, in the light of present expe- 
rience, that when pressure from below by water, air, or gas, which is the only 
efficient mode of treatment short of the knife, has been tried sufficiently long 
and sufficiently often without result, it is the duty of the physician to seek sur- 
gical advice in reference to laparotomy, as he would in a case of hernia, espe- 
cially since, under Lister's antiseptic method, the danger from severe operations 
appears to be considerably diminished. It may be added that laparotomy 
performed on the first or second day will be much more likely to save life in 
ordinary cases than if performed later, since the strangulated intestine is 
soon badly damaged, and a local peritonitis is likely to be developed any time 
after the first forty-eight hours. 

When an intussusception has reached that stage in which active inter- 
ference by injections, inflation, or laparotomy is no longer proper, the physician 
can only prescribe opiates with sustaining measures and an emollient poultice 
over the abdomen, and must await the result. The diet should consist of 
beef juice and other concentrated nutriment which leaves little residuum. 
Vomiting, which is so common, is best controlled by bismuth and opiates; 
convulsions require the bromide of potassium and an enema of three to five 
grains of chloral hydrate dissolved in a little water. 



CHAPTER XIII. 

APPENDICITIS, TYPHLITIS, PERITYPHLITIS. 

The portions of the intestinal tract which are involved in these inflam- 
mations are the caecum and' appendix vermiformis, which are lined by mucous 
membrane continuous with that of the colon. Inflammation of the caecum 
and of the appendix so frequently coexist that they may be considered 
together. 

^ American Journal of the Medical Sciences, for July, 1874. 



ETIOLOGY, 867 

According to Gerlach, a fold of the mucous membrane after the age of 
three years ordinarily forms a valve at the upper end of the appendix, so as 
to prevent fecal matter from entering it. RansohofF states that this valve 
prevented rectal injections which he employed, and which reached the caecum, 
from entering the appendix. This anatomical fact prevents the more frequent 
occurrence of appendicitis from the lodgment of foreign substances. The 
appendix is covered by peritoneum on all sides and in its entire length, and 
this peritoneum forms underneath it a mesentery designated the mesenteriolum, 
which attaches it to the posterior wall of the right iliac fossa, and from its 
length allows considerable mobility of the appendix. If the appendix becomes 
inflamed and perforated by the lodgment in it of a foreign substance, a local- 
ized peritonitis inevitably results. The caecum anteriorly and laterally is 
also covered by peritoneum. In rare instances its posterior surface is attached 
by loose connective tissue to the posterior wall of the iliac fossa, and is there- 
fore without peritoneal covering. Eansohoff states that in 63 post-mortem 
examinations he found the posterior surface of the caecum covered by peri- 
toneum in all but 2 cases. Therefore, contrary to the statement of Oppolzer, 
in posterior inflammation of the caecum extending through all its laj^ers the 
peritoneum does not escape. Perityphlitis, as the inflammation is designated 
when, whether it begins in the caecum or appendix, it extends to their perito- 
neal covering and produces the characteristic exudation, is said to be more 
frequent in males than in females. In Matterstock's collection of cases 51 
were males and 21 females, and in Fitz's cases 80 per cent, were males, 20 
per cent, females. 

No age is exempt from perityphlitis, but, according to all writers whom I 
have consulted, a large majority of the cases occur under the age of thirty 
years. Matterstock has the records of 72 cases under the age of fifteen 
years, tabulated as follows : 

Cases. 

Under 2 years 2 

From 2 to 5 vears, inclusive 10 

5 " 10 ' " " 25 

'' 10 " 15 " " 35 

The youngest reported case, so far as I know, was one related by Demme. 
A female infant, aged seven weeks, had been fed from the age of seven days 
with porridge. In the third week she was fretful. In the seventh week she 
was very feverish, was tympanitic, and had tenderness especially marked in 
the right iliac region. The symptoms indicated peritonitis, and death occurred 
soon afterward. At the autopsy the lesions of difl"use peritonitis were found, 
most marked around the caecum and appendix. The appendix was distended 
with fecal substance, which, examined under the microscope, w^as found to 
consist of hardened masses of the porridge, from wiiich, apparently, the 
inflammation had originated without producing perforation. 

Etiology. — The most common cause of the inflammations which we are 
considering is the lodgment and impaction in the appendix or csecum, or both, 
of fecal matter or hard, indigestible foreign bodies which produce inflamma- 
tion, and sometimes perforation, by their pressure. In 146 cases of perfora- 
tion of the appendix collated by Matterstock, fecal concretions were present 
in 63 ; foreign bodies difi'erent from concretions in 9 ; neither fecal masses 
nor hard bodies in 8 ; and in the remaining cases the records do not mention 
the presence of any substance likely to cause inflammation. In 49 cases of 
fatal perityphlitis in children, perforations had occurred in 37. The analysis 
of 152 cases collated by Fitz gives a very similar result to that obtained 
from the examination of Matterstock's records ; but Hagen ascertained the 



858 APPENDICITIS, TYPHLITIS, PERITYPHLITIS. 

presence of fecal concretions in 692^ per cent., and hard bodies not concretions 
in 30 J per cent., of the cases of perforation of the appendix. We must there- 
fore regard foreign substances, either concretions or other hard bodies which 
act mechanically by pressure, as the common cause of appendicitis, perfora- 
tion of the appendix, and perityphlitis. 

The fecal concretions found in the appendix are single or multiple, and 
of different degrees of hardness. The hardest masses sometimes exhibit con- 
centric layers, and contain phosphate of calcium. Exceptionally, the concre- 
tion has a nucleus of some solid substance in the interior. The foreign bodies 
which lodge in the appendix and cause ulceration are numerous. In a case 
in my practice an over-baked bean, hard and black, perforated the appendix 
and caused an abscess, which by rupturing produced fatal peritonitis. Among 
the substances which have caused perforation and been recovered we may 
mention small buttons, beads, grape-seeds, cherry-stones, orange-seeds, raisin- 
seeds, apple-seeds, and seeds of other fruits. 

Perityphlitis may also result from traumatism, as a blow or kick upon the 
right iliac region, and from tubercular or typhoid ulcers of the intestine. The 
exciting cause of the perforation, and of the consequent inflammation, is 
sometimes trivial, and under ordinary circumstances inadequate, such as 
emetics, purgatives, clysters, vomiting, sneezing, defecation, coughing, and 
dancing; but it is supposed that when so trivial a cause produces so grave a 
result an ulcer or abscess was present, and in such a state that a slight injury 
was sufficient to rupture it. 

Anatomical Characters. — The initial lesions take place in most 
instances in the appendix. Atrophy or necrosis of its epithelium occurs 
from pressure of the foreign substance; then the intestinal microbes invade 
the exposed subepithelial tissue, causing septic inflammation. This inflam- 
mation extends through the muscular coat to the subperitoneal connective 
tissue and peritoneum, causing a local peritonitis, or it ceases before reaching 
the peritoneum, producing gangrene or ulceration of the underlying tissues ; 
and as they contract in healing, the lumen of the appendix may be oblit- 
erated and its shape changed. Sometimes the appendix is nearly or quite 
obliterated by the inflammatory process, its place being occupied by cicatri- 
cial tissue, or its proximal end may be obliterated while its distal end remains 
open. A retention-cyst then results, which may subsequently be inflamed, 
and may at some point be destroyed by gangrene or ulceration, so that the 
retained fecal substance escapes, causing peritonitis. Occasionally similar 
changes occur in the cgecum. Thus Burne relates the case of a girl of twelve 
years who died after two years' sickness. The walls of the caecum had under- 
gone contraction through bands of connective tissue, so that its surface was 
irregular and uneven and its capacity much reduced. 

In the common favorable cases of perityphlitis a fibrinous exudation 
occurs over the inflamed parts, so as to limit the extension of the disease and 
prevent the escape of pus or fecal matter. This adhesive peritonitis around 
the ulcerated appendix is common. The extent and gravity of the peritonitis 
depend on the size of the perforation and the quantity of pus or feculent 
matter that escapes. If the substance which escapes from the perforation 
be considerable and highly irritating, the perityphlitis is of course severe and 
pus results, forming the perityphlitic abscess. But Balzer states that the 
abscess is much less frequent in children than in adults. Its location depends 
upon the place of perforation. It is stated that in most instances the centre 
of the abscess is behind or alongside the caecum, and if it extend upward its 
walls consist of intestine and the posterior and lateral parietes of the abdo- 
men. If the appendix be long and extend to the brim of the pelvis minor, 
and the perforation be near its distal end, a somewhat rare occurrence, the 



SYMPTOMS. 859 

abscess may press upon the rectum or uterus. The presence of fecal matter 
with its microbes in the pus renders it very irritating and poisonous. 

The abscess, left to itself, may open in any direction. It sometimes dis- 
charges into the intestine, either into the lower end of the ileum, the caecum, 
ascending colon, or rectum, through an opening that is quite small in the 
mucous membrane, but larger in the other intestinal coats. Evacuation of 
the pus per rectum, sometim.es tinged with blood, has been regarded as favor- 
able from the time of Dupuytren. It occurred in 18 per cent, of the cases 
collated by Fitz, the pus breaking into the intestine at some point above, and 
escaping by the rectum. But the result is not always favorable when the 
abscess breaks into the intestine, for after the pus has been evacuated fecal 
matter may escape from the intestine through the opening, carrying with it 
microbes which may poison the system and set up septic fever. Of 6 cases 
related by Demme in which the abscess broke into the intestine, 3 subse- 
quently died. Henoch states that abdominal abscesses are very prone to 
escape at the umbilicus, since this is the weakest part of the abdominal wall. 
Rarely the pus makes a passage into the bladder, and if this occur, cystitis, 
due to the presence of purulent and fecal matter, may result. The inflam- 
mation has also, in a case mentioned by Eisenschiitz, extended from the per- 
forated appendix to the right ovary, producing purulent inflammation in this 
organ. Extension of the inflammation from the perforated appendix to and 
around the contiguous blood-vessels may produce disastrous results. The 
superior mesenteric vein, which conveys blood from the caecum and appendix 
to the portal vein, sometimes becomes the seat of thrombosis, the circulation 
in its branches being interrupted by the presence and pressure of inflamma- 
tory products. Detached particles of the thrombi, conveyed through the por- 
tal vein to the liver, produce septic inflammation and abscesses in this organ. 
Matterstock has the records of eleven cases in which the liver became involved 
in this manner.' Occasionally the abscess ascends along the colon and behind 
the liver, becoming subdiaphragmatic, and cases have been reported in which 
it entered the right pleural cavity. Tillmann states that in 22 cases of fecal 
fistula extending into the pleural cavity, 6 originated from perforations in the 
■appendix. The abscess penetrating the retro-peritoneal tissue may extend 
to the kidney, so as to become perinephritic, or it may descend along the 
psoas and iliac muscles, even under or below Poupart's ligament. Cases are 
reported in which it burrowed under the gluteus maximus muscle or in the 
perirectal tissue, occupying the sacral or coccygeal region. 

Evidently, inasmuch as the appendix is invested by peritoneum, its per- 
foration and the escape of fecal substance or a foreign body, which produces 
the abscess described above, cannot occur without a localized peritonitis behind 
and below the caecum, where the appendix lies. But a more serious and 
ordinarily fatal result sometimes follows — to wit, the occurrence of acute dif- 
fuse peritonitis. This may take place immediately after the perforation, but 
frequently an abscess forms, perhaps of little extent, around the appendix, 
and it may continue for weeks or months without producing any dangerous 
symptoms. Finally it bursts, and its contents escape into the general peri- 
toneal cavity, producing an acute peritonitis, which rapidly extends over the 
peritoneal surface. A large proportion of the cases of perforation of the 
appendix if left to themselves terminate, after a time, in this manner, in peri- 
tonitis, which from its extent and severity is usually fatal. This was the 
result, according to Volz, in 31 of 39 cases, and, according to Cless, in 7 out 
of 8 cases. 

Symptoms. — The initial symptom of the inflammation, typhlitis, appen- 
dicitis, and perityphlitis is pain, more or less severe, in the region of the 
appendix or caecum, perhaps at first paroxysmal, with intervals of comparative 



860 APPENDICITIS, TYPHLITIS, PERITYPHLITIS. 

ease, and accompanied by tenderness. The patient is apt to have nausea and 
even vomiting, constipation or diarrhoea, flatulence, and tenesmus, so that 
experienced physicians sometimes diagnosticate indigestion, not aware of the 
serious malady which is impending. These symptoms in the initial period 
frequently abate for a day or two, and the patient is able to be about, but 
they return with equal or greater severity. 

When the disease is fully established the severe pain in the cascal region 
is constant, and the patient takes to bed, unable to stand upright or to walk. 
He inclines forward and to the right, and his right thigh is flexed to relieve 
the tension. Sometimes he refers the pain to the epigastrium or the abdo- 
men, and it is increased by coughing, by full inspiration, and by extension 
of the right thigh. The patient is quiet in bed or he moves from restless- 
ness. Distension of the stomach with food or drinks increases the pain. 
Vomiting of the ingesta mixed with mucus and bile is common, and eructa- 
tions of gas may occur. Occasionally these symptoms are preceded by a 
chill, but less frequently in children than in adults. The following are the 
symptoms commonly present : anorexia, thirst, fever with morning remissions 
(101° to 103° F.), accelerated pulse, features indicative of severe sickness, 
sometimes icteric hue of skin and conjunctiva, perhaps dysuria, scanty uri- 
nation or retention of urine, diarrhoea or constipation ; abdomen flat and muscles 
tense at first, but subsequently abdomen tympanitic ; tenderness on pressure 
at first in the right iliac region, but subsequently more general ; prominence 
of the ileo-caecal region, at first from gas, subsequently from exudates ; a 
caecal tumor, tender and immovable; adjacent loops of intestine distended. 
Such are the symptom,s and phenomena that attend this disease. Pressure 
on the crural plexus may cause numbness, pain, or other abnormal sensation 
in the right leg and the external genital organs. Pressure on the iliae 
vein may retard the return circulation from the leg and cause oedema of 
the limb. 

The progress of this disease and its gravity vary greatly in diff"erent 
cases. In the mildest forms of the inflammation the pain, nausea, fever, ileo- 
cascal tenderness, and fulness gradually abate, and in two or three weeks the 
health is restored ; or the symptoms may continue longer, but finally yield 
after the discharge per rectum of gas and off'ensive feces. A deep-seated 
induration and soreness, gradually abating, may remain at the seat of the 
disease for months, and the patient may complain of aching or pain after a 
full meal or active exercise. When the abscess opens into the intestine, the 
dangerous symptoms abate rapidly, and the patient, as a rule, quickly begins 
to convalesce. 

In other cases the symptoms continue, but with some remission, due ta 
the fact that the abscess, which does not discharge, becomes surrounded by 
condensed connective tissue which limits its extension. Then, perhaps after 
some unusual eff"ort or a blow or pressure upon the inflamed part, an aggra- 
vation of symptoms occurs. Purulent or septic matter has probably escaped 
at some point, and peritonitis may have resulted, or burrowing of pus, as has 
been described above, or septic inflammation in some important organ. The 
sudden advent of alarming symptoms when the patient has been compara- 
tively comfortable, severe and general abdominal pain, prostration, rapid 
pulse (150 to 160), a high temperature (105° or 106°), or abnormally low 
for the other symptoms, painful respiration, tenseness of the abdominal mus- 
cles, followed by tympanites and distension, indicate rupture of the abscess, 
general peritonitis, and rapidly approaching death, unless early and imme- 
diate laparotomy be performed and the peritoneal cavity be irrigated by a 
warm antiseptic lotion. In this alarming state, vomiting, gaseous eructa- 
tions, constipation, more rarely diarrhoea, retention of urine, clammy perspi- 



DIAGNOSIS. 861 

rations, hiccough, flexed thighs, pallor, and finally collapse, indicate the fatal 
progress of the attack. 

To add to the gravity of the situation, septic inflammations in other parts 
sometimes start up, as empyema or pericarditis, cystitis, perhaps with per- 
foration of the bladder, inflammation around or within the female genital 
organs or in the retro-peritoneal connective tissue. 

On the other hand, it must be remembered that in a considerable propor- 
tion of cases the abscess is so encapsulated that septic poisoning and diffuse 
peritonitis are prevented, and after a time it begins to point at some place 
where it has approached the surface, and the pus escapes spontaneously or 
is released by the knife, and the patient immediately begins to recover. 
Prof. Henoch has witnessed the discharge of pus through the umbilicus, and 
he believes that this is quite liable to occur, from the fact that the abdomi- 
nal wall is thin and yielding in the umbilical region. 

Of the symptoms enumerated above, pain is one of the most constant, and 
was present in 84: per cent, of the cases collated by Fitz. It is of course less 
severe if the inflammation is localized in the ileo-caecal region, and of little 
extent, than when it occupies a wider area. Fitz, in his examination of the 
records of patients, ascertained that the pain was referred to the ileo-caecal 
region in 48 per cent, of the cases of appendicitis and in 60 per cent, of 
perityphlitis, to the abdomen in 36 per cent, of the cases of appendicitis and 
in 34 per cent, of the cases of perityphlitis. In a few instances the pain 
was referred to the hypogastric, umbilical, or epigastric regions, and in rare 
instances to the region of the liver, left iliac fossa, and the right hip and 
groin. Cessation of pain when the other symptoms are severe indicates 
commencing collapse. 

Vomiting is one of the most common symptoms. It was absent in only 
2 of the 72 cases collated by Matterstock, and was present in Pepper's 13 
cases. It appears to be more common in children than in adults. Diarrhoea 
was present in 33.3 per cent, of Matterstock's cases, and constipation in 46.6 
per cent., alternating constipation and diarrhoea in 15.5 per cent., and nor- 
mal stools in 4.5 per cent, of the cases. According to Pott, diarrhoea is 
more common than constipation in children,^ and in fatal cases approaching 
termination severe colliquative diarrhoea sometimes occurs. 

More or less fulness and induration can usually be detected in the ileo- 
caecal region at an early as well as late stage of the disease, but a distinct 
tumor is only occasionally perceptible. According to Pepper, in 19 children 
with this disease a tumor could be detected in only 3 instances, A dull per- 
cussion sound in the right ileo-caecal region is common, but occasionally, even 
when there is considerable inflammatory induration, loops of intestine dis- 
tended with gas lie over the seat of inflammation, so that the percussion 
sound is resonant. The temperature usually ranges from 100° to 103° or 
104°, It is sometimes remittent. In a case treated by the late Dr. H, B. 
Sands the temperature fell from 101.6° before laparotomy to 98.5° imme- 
diately after the operation, and it remained below 100° during convalescence. 
A sudden rise in temperature indicates extension of inflammation or perhaps 
the occurrence of septic inflammation in organs not previously involved. A 
sudden fall of temperature when other symptoms are grave, like cessation of 
pain, indicates collapse. 

Diagnosis. — Recurring pain or tenderness in the cascal region at inter- 
vals of a few weeks should excite suspicion of the presence of a foreign sub- 
stance in the appendix. Dr. C. E. With^ found that such recurring attacks 
preceded the severe disease for weeks, months, or even years in certain cases, 

^ Jahrbuchjilr KinderheiL, N. F. xiv. 

^ Peritonitis Append icularis, etc., Kjolienhavn, 1879. 



862 APPENDICITIS, TYPHLITIS, PERITYPHLITIS. 

and in the large number of cases which he collated Matterstock ascertained 
that these occasional attacks of pain and tenderness preceded the disease in 8 
per cent, of the children affected. Sometimes the accumulation of fecal mat- 
ter in the caecum can be determined by palpation, since it produces a " doughy " 
feel. The diagnosis of this inflammation from invagination is not difficult, since 
the latter occurs chiefly in infancy, is attended by a tumor more centrally located 
in the abdomen than the ileo-caecal induration which we are considering, and 
is attended often by bloody stools and fecal vomiting. Dr. V. P. Gibney^ 
states that four children with perityphlitis had been brought to his orthopae- 
dic hospital in the belief that they had hip disease, and had been treated for 
it ; but a more careful examination of such cases, especially under ether, 
shows that the hip-joint is not afl"ected. The swelling in hip-joint disease is 
lower down than the perityphlitic induration. Besides, perityphlitis does not 
produce the change in the appearance of the hip when examined from 
behind, or in the position of the foot, which we observe in hip disease. N. 
Senn'^ recommends rectal injection of hydrogen gas as a means of determin- 
ing the presence of perforation of the caecum or appendix, since in case of per- 
foration the gas enters the peritoneal cavity, and laparotomy without delay is 
indicated. The diagnosis from a psoas abscess may be made by attention to 
the following facts : This abscess occurs gradually, without symptoms refer- 
able to the intestines or peritoneum, and without the ileo-caecal induration of 
perityphlitis. Moreover, the abscess usually descends along the psoas mus- 
cle and forms a swelling under Poupart's ligament, or it extends along the 
thigh under the fascia. 

Prognosis. — This varies greatly in different cases. If the inflammation 
be of little extent and encapsulated, and sepsis do not occur, the prognosis is 
good. On the other hand, if the perforation of the caecum or appendix be 
of considerable size, with considerable escape of feculent matter, loaded as it 
is with microbes, the severe inflammation which results in the peritoneum or 
retro-peritoneal tissue, with perhaps consecutive septic inflammation in adja- 
cent organs or tissues, to which septic matter has been conveyed by the lym- 
phatics or blood-vessels, a fatal termination is almost certain. It is evident 
that the statistics relating to the result, as ascertained by diff'erent writers, 
vary according to the average severity of the cases whose records they con- 
sult. The following statistics have been published, showing the mode of 
termination of appendicitis, typhlitis, and perityphlitis, considered as one 

disease : 

Authors. Deaths. Recoveries. 

Volz 39 10 

Bamberger 18 55 

W. T. Bull 33 34 

Matterstock 49 21 

With 12 18 

Demme 27 9 

According to Matterstock, age influences the result in a measure, since of 
12 patients under the age of six years, 11 died; of 24 patients between the 
ages of six and ten years, 15 died; and of 34 patients between the ages of 
ten and fifteen years, 23 died. A diffuse peritonitis, whether resulting imme- 
diately from the perforation or from rupture of an abscess which has been 
previously encapsulated and indolent, is usually fatal. Evacuation of the 
abscess into the caecum or rectum justifies a favorable prognosis, though 
some die in which this occurs. Evacuation of pus through the abdominal 
walls, if it take place at an early date, is also regarded as favorable. Lapa- 
rotomy, which consists in evacuation of the pus through the abdominal walls, 

1 Amer. Jour, of Med. ScL, 1881. ^ j^^^^.^ ^j ^/^g ji.,ner. Med. Assoc., June 23, 1888. 



TREATMENT. 863 

if performed at the proper time and with antiseptic precautions, increases the 
chances of recovery. According to Noyes/ in 100 such operations the mor- 
tality was only 15. But according to Bull, the result is not so favorable if 
the abscesses burrow their way to the surface and open w^ithout surgical 
assistance, for of 28 such abscesses, 11 were fatal. 

How long patients may live in fatal cases after the occurrence of severe 
symptoms has been investigated by Fitz, who found that in 176 cases 34 per 
cent, died in the first five days, more than half in the first week, 31 per cent, 
in the second week, and 4 per cent, in the third week. In those mild cases 
in which the inflammation in the csecal region is of slight extent and the 
patient is soon convalescent, a sudden aggravation of symptoms sometimes 
occurs from breaking loose of the inflammatory products or septic absorp- 
tion, and the case ends fatally. 

Treatment — Prophylactic. — Children should have plain and easily- 
digested diet, from which seeds or other indigestible substances are 
removed so far as possible. They should be instructed to reject the 
seeds of the ordinary fruits which they are allowed to eat, since seeds 
are the off"ending substances which cause appendicitis and perforation in 
so large a proportion of cases. Daily fecal evacuations should be pro- 
cured, so as to prevent fecal accumulation in the caecum. If there be 
complaint of colicky pain in the abdomen while the bowels move reg- 
ularly, or if there be occasional pain or aching in the caecal region, a 
careful examination should be made in order to ascertain if there be 
tenderness or induration at the point complained of, and if so a quiet 
life with open bowels should be enjoined. By such measures the threat- 
ening symptoms may pass off". 

Curative. — Prof. Henoch of the University of Berlin, whose opinions 
relating to the diseases of children always claim attention, if not acceptance, 
on account of his large experience, says that whether the inflammation occurs 
from over-distension of the caecum by fecal masses or from concretions in 
the appendix, the symptoms are the same as in later life — to wit, pain in the 
eaecal region, which is likely to extend over " a large part of the peritoneum ; 
the frequent formation of a tumor by the exudation, which not infrequently 
terminates in suppuration ; the repeated relapses, etc." Henoch states that 
he keeps the intestines perfectly quiet by opium, and only gives castor oil or 
calomel when prolonged constipation and palpation indicate the presence of 
a large fecal accumulation in the caecum ; otherwise, he abstains from purga- 
tives, applies a few leeches, without after-bleeding if there be much tender- 
ness, gives an emulsion of oil (emulsio oleosa), with the aqueous extract of 
opium every two hours, and uses constantly the ice-bag over the caecum. 
When with this treatment the pain and tenderness cease, he states that defe- 
cation usually occurs spontaneously or is produced by a simple enema or a 
dose of oil. The following remark might be thought to be an exaggeration 
were it not for the well-known accuracy and high professional standing of 
Prof. Henoch : " When this treatment was begun early enough recovery 
ensued in almost all cases, and if a swelling had been formed by the exuda- 
tion, its transition into suppuration was prevented even in children who in 
the course of a few years had been repeatedly admitted to the hospital on 
account of relapses." The treatment detailed above, employed and recom- 
mended by Prof. Henoch, is in my opinion the best that can be prescribed 
for typhlitis, appendicitis, and perityphlitis before suppuration has occurred. 
The use of laxatives, even of laxative enemata, should be postponed until 
the tenderness and other inflammatory symptoms have to a considerable 
extent abated by the use of the ice-bag, and opium in sufficient doses to allay 

^ Trans. Rhode Island Med. Soc, 1882. 



864 APPENDICITIS, TYPHLITIS, PERITYPHLITIS. 

restlessness and procure sleep. If, when the inflammation has been subdued, 
we ascertain by palpation the presence of fecal masses in the caecum, a large 
clyster of warm water, containing one ounce of glycerin and one of sweet 
oil, may be prescribed, or perhaps, as recommended by Henoch, a dose per 
crem of castor oil or calomel may be given. Even in the commencement of 
the treatment, if there be the history of constipation, and on palpation the 
caecum appears to be distended with fecal matter, it is proper to employ a 
large clyster of warm water, containing one ounce of glycerin and one of 
sweet oil, in order to remove a chief cause of irritation. The diet should 
consist of liquids that leave little residuum, as the beef peptones and pep- 
tonized milk. Carbonized water may be allowed to relieve the thirst or 
nausea. If the case result favorably, the child should lead a quiet life, 
avoiding violent exercise during and after convalescence, for relapse is not 
infrequent. 

If the inflammation continue and suppuration occur, a perityphlitic 
abscess forms, which requires incision if the diagnosis be clearly made. In 
America the advantages of early liberation of the pus in ileo-caecal abscesses 
was brought to the notice of the profession by the late Prof. Willard Parker, 
whose first case of successful operation occurred in 1843. Since this time 
the treatment of perityphlitic abscesses by incision has been practised in 
numerous instances, so that Dr. R. F. Noyes in 1882 was able to collate the 
records of 119 cases, only about 16 per cent, of which were fatal. ^ 

Dr. Sands strongly objected to the use of the exploring needle at an early 
stage of the inflammation, employed for the purpose of determining the 
presence or absence of pus, since it might penetrate the healthy peritoneal 
cavity and pierce the intestine or pus-cavity, and when withdrawn the foul 
substance adherent to it would probably infect the peritoneum and cause a 
difi"use peritonitis. G. Buck, Wier, Noyes, and Bull advise, if the presence 
of pus be determined by the needle, to leave it in situ, that it may serve as a 
guide in making the incision. Morton states that the aspirator needle should 
never be used, and Eansohofl" also objects to it. Dr. Lange ^ in making the 
incision and entering the peritoneal cavity, finding that the tumor was covered 
by omentum, closed the opening and made the cut farther to the right, where 
the peritoneum was adherent to the tumor, and the patient recovered. 

Sands recommends making a vertical incision over the caecum, as afford- 
ing the readiest approach to the diseased parts. Noyes, Parker, Hancock, 
and others make the incision, four inches in length and even longer, in a line 
parallel with the outer half of Poupart's ligament. Hadden and Bontecou 
make a curved incision along the crest of the ileum, and others, as Gibney 
and Parker, make the incision at the most prominent part of the tumor, and 
nearer the median line than most other operators. 

Laparotomy, or the opening of the abdominal cavity for the purpose of 
■evacuating the perityphlitic abscess, has been performed a considerable num- 
ber of times during the last ten years, and cases have been published show- 
ing very favorable results. But it must be borne in mind that favorable 
cases are much more likely to be reported than the unfavorable. Dr. Sands 
reported the following case in 1888 : A boy, sick two days, had a pulse of 
130, temperature 101.6°, respiration 32. An incision carefully made 
revealed the parietal peritoneum thickened and opaque, and the hypodermic 
needle introduced drew pus. A free incision was then made, and a little gas 
and one ounce of fetid pus escaped. The caecum and loops of the small 
intestines were covered with pus. The peritonitis, not being restricted by 
adhesions, was diff"use. Three fecal concretions escaped from a perforation 
in the appendix. The abdominal cavity was irrigated by warm water, and 
1 Trans, of Rhode Hand Med. Soc., 1882. . '' N. Y. Ned. Jour., Mar. 3, 1888. 



TREATMENT. 865 

then by half a pint of corrosive-sublimate solution, 1 part to 1000. The 
wound was partially closed by interrupted silk sutures, the part not closed 
being packed by iodoform gauze extending to the loops of small intestine. 
The drainage-tube was not used. The patient immediately began to improve 
and recovered.' Homans relates the case of a boy of eleven years who had 
had pain in the ileo-caecal region five days, and had been in bed three 
days. He had dulness and tenderness on percussion in the right iliac region, 
without swelling ; pulse 120, temperature 102.4°. The incision, made half 
an inch anterior to the crest of the ileum, revealed healthy loops of intestine, 
but below and behind them were deeper loops agglutinated by the inflamma- 
tion. On separating the adhesions a cavity was reached, from which two 
ounces of fetid pus escaped, which, so far as possible, was removed without 
flowing over the healthy peritoneal surface. Double rubber tubes were 
introduced and the wound was closed around them. This case occurred 
before antiseptic measures were so generally employed as at the present 
time, but the patient progressively improved, and was out of bed after three 
weeks, the discharge from the tubes being abundant during two weeks. 

Such cases show what may be accomplished by surgical treatment of the 
perforated appendix and perityphlitic abscess, even in cases in which difi'use 
peritonitis has resulted ; but of course when peritonitis not limited by adhe- 
sions occurs, death will inevitably result in a considerable proportion of cases 
under any treatment. 

Removal of the perforated and diseased appendix, when it can be readily 
brought into view, has been recommended and performed by Sands, Morton, 
Hoflfmann, and others, and it is generally advised by the writers of the 
various monographs on this disease, since it is a source of irritation, and by 
the subsequent escape of fecal matter might cause a renewal of the inflam- 
mation. But in a large proportion of cases the appendix lies at the bottom 
of the cavity surrounded by adhesions, so that it cannot be removed without 
considerable cutting and tearing of the parts which surround it, and perhaps 
producing an opening through which inflammatory products may escape into 
the peritoneal cavity. Attempts to remove it under such circumstances 
would not be justifiable. If it be accessible, the cautious and experienced 
surgeon will understand in what way its removal can be best accom- 
plished. 

1 iV. Y. Med. Jour., Feb. 25, 1888. 
55 



SECTION IT. 
DISEASES OF THE GENITO-URINARY ORGANS. 



Uric- Acid Infarctions. 

Infarctions of uric acid or the urates are very common in new-born 
infants. They are seen, if an opportunity of examining the kidneys occurs, 
as yellowish-red lines in the tubules or lying in the pelvis of the kidney, 
forming small yellowish granules. As they are washed away by the urine, 
we often find them upon the diaper. The irritation produced by these infarc- 
tions sometimes causes painful micturition. Children a few months old often 
fret or cry from pain during urination in consequence of the irritating action 
of the uric acid, while in the intervals between the passing of water they 
may or may not be free from suffering. Perhaps they pass only a few drops 
of urine with straining, and in it we find crystals of uric acid or the urates. 
Urine highly acid from the presence of this substance causes a burning pain 
in the urethra, and sometimes redness not only of the urethra, but even of 
the labia over which the urine flows. Although infants perhaps suffer most 
from this cause, the same condition not infrequently occurs in older children. 
Their urine, previously normal, becomes unduly acid from some error in feed- 
ing or in the digestive process, and uric-acid crystals or concretions form. 
An exaggerated secretion of mucus occurs from the surface of the bladder 
or from the urinary canal in consequence of the irritation produced by the 
acid, and sometimes pus-cells are also seen under the microscope mixed with 
the mucus. 

The state of the urine described above should be at once rectified, for it 
furnishes the conditions in which calculi form either in the pelvis of the kid- 
ney or in the bladder. Urine unduly acid and irritating probably at first 
causes catarrh of the delicate membrane lining the tubules and pelvis of the 
kidneys, and if the irritation be sufiiciently severe the catarrh extends along 
the ureters to the bladder, causing a degree of cystitis. Now, a catarrah of 
the pelvis of the kidney or the bladder greatly increases the tendency to the 
formation of calculi, since the crystals become imbedded in the mucus, which 
serves to agglutinate them. Uric acid, when so abundant in the urine as to 
cause symptoms, should be at once treated and the acid neutralized by an 
alkali. The liquor potassae, employed as recommended in our remarks on 
the treatment of Enuresis, is the best alkali for this purpose. For an infant 
of one year, two drops sufficiently diluted in mucilage will be sufficient, 
repeated in three or four hours. 



Enuresis. 

Enuresis, or incontinence of urine, is a common and troublesome infirmity 
in children. It occurs both in boys and girls, but is more common in the 



ENUEESIS. 867 

former than in the latter. In many children it dates back to infancy, but 
others have a respite from it in the years immediately succeeding infancy 
until the sixth or seventh year, when it returns. It may be diurnal as well 
as nocturnal, interfering seriously with the comfort of the child and render- 
ing his schooling inconvenient ; but the annoyance which it causes is com- 
monly most at night, and it is for nocturnal enuresis that the physician is 
most frequently consulted. The child may pass his urine in bed every night, 
or even more than once each night, or there may be occasional nights of 
immunity. 

The bladder consists of three concentric coats: 1. On the outside the 
peritoneal, which covers the posterior, the superior part of the lateral, and 
the anterior aspects of the organ ; 2. The muscular, which chiefly concerns 
us at present, and which consists of two layers — the one external, the fibres 
of which have a general longitudinal direction ; the other internal, whose 
fibres are circular. The circular fibres become more abundant, producing 
greater thickness of this layer, at the urethral orifice, and they extend a dis- 
tance over the urethra. This increase in the number of circular muscular 
fibres at the urethral orifice constitutes the sphincter vesicae. The fibres in 
the muscular coat of the bladder are unstriped, and are not under the control 
of the will. 

A second sphincter, which aids materially in the retention of urine, is 
formed by the compressor urethras. This muscle, arising by aponeurotic 
fibres from the ramus of the pubes, surrounds the whole membranous por- 
tion of the urethra, extending from the prostate to the bulbous portion. The 
compressor urethras is a striped muscle, and its action is therefore controlled 
by the will. Certain accessory muscles influence the retention as well as the 
expulsion of urine — to wit, the levator ani, acceleratores urinae, and the abdom- 
inal muscles. 

Nerves. — The muscular coat of the bladder receives its nerves from the 
hypogastric plexus, which belongs to the sympathetic system, although fila- 
ments enter the plexus from the spinal system. The innervation of the blad- 
der is therefore twofold, that derived from the sympathetic system predom- 
inating over that from the spinal system, as shown by the relative number of 
filaments from the two sources. According to Belfield, the spinal centre of 
the motor nerves of the bladder is in the vicinity of the third lumbar verte- 
bra ; but Budge, in his experiments on rabbits, locates it in this animal in 
the vicinity of the fourth lumbar vertebra. The spinal centre of the nerv- 
ous supply of the bladder, says Coulton, "is connected with the brain by a 
strand of fibres which may be traced from the cerebral peduncle along the 
anterior columns of the spinal cord." The neck of the bladder, including 
the sphincter vesicae, derives nervous fibres directly from the anterior or 
motor roots of the 4:hird, fourth, and fifth sacral nerves ; and it is more 
abundantly supplied with nervous filaments than is the muscular coat of the 
organ. That the sphincter vesicae is under the control of the will is there- 
fore apparent from the anatomical characters, since a strand of fibres con- 
nects the peduncles with the motor centre of the bladder in the spine, and 
this centre connects with the sphincter through the spinal nerves. In nor- 
mal urination the sphincter is relaxed by the volition of the individual, while 
the muscular coat of the organ, being under the control of the sympathetic 
system and involuntary in its action, expels the urine as soon as the sphinc- 
ter is open. 

The pudic nerve also sustains an important relation to the function of the 
bladder. Arising from the sacral plexus, it is distributed " to the base of the 
bladder, the prostate, the intef:;ument of the penis, scrotum, and perineum, 
the urethral muscles and mucous membrane, and the sphincter of the anus ; 



868 DISEASES OF THE GENITO-UEINABY ORGANS. 

in the female, the uterus, vagina, and vulva are supplied by branches of the 
same nerve." Knowledge of the distribution of the pudic nerve enables us 
to understand the manner in which disease or abnormal conditions of the 
genital organs and anus disturb the functions of the bladder. Irritation 
of the inferior branches of this nerve aiFects the action of the superior 
branches, or those which supply the base of the bladder and the urethral 
muscles, so as to produce in certain patients dysuria or incontinence, or 
both. 

Etiology. — In all cases the urine should be examined, since the cause 
of the enuresis is often discovered in the deviations in it from the normal 
state which are apparent on inspection. The chief causes may be grouped 
as follows, but often two or more of them are present in the same case : 

1. Too great acidity of the urine. The urine in its normal state is acid 
from the presence of the acid phosphate of sodium (Robin), but in certain 
conditions the acidity becomes so great that the urine is unduly stimulating 
to the surface of the bladder. Now, stimulating or irritating urine causes 
the bladder to contract, just as an irritating substance in the intestines 
increases the peristaltic and vermicular movements of this tube. Exces- 
sive acidity of the urine is commonly due to the presence of uric acid, 
resulting from decomposition of the urates ; but in certain conditions lactic 
and hippuric acids, resulting from faulty digestion, appear in the urine 
(Robin) ; urine unduly acid renders its retention difficult, except in mod- 
erate quantity, so that enuresis results. 

2. Increased quantity of urine. This sometimes occurs from the free 
use of liquids, as of water or milk. Renal disease, attended by an exag- 
gerated excretion of urine, sometimes produces enuresis. Henoch ^ says : 
'' I would advise you never to omit an examination of the urine, because 
cases of diabetes mellitus and chronic nephritis are known which were first 
manifested by nocturnal incontinence." 

3. A vesical calculus. This is an infrequent cause, but when present it 
is likely to produce both diurnal and nocturnal enuresis. If micturition be 
frequent and painful by day and by night, if the urine contain a large 
amount of mucus or muco-pus so as to render it turbid, and if the dysuria 
and frequent urination be not soon relieved by treatment, a calculus is prob- 
ably present. In such cases the bladder should, of course, be sounded by 
the proper instrument to render diagnosis certain. 

4. The muscular coat of the bladder may have an exaggerated contractile 
power in itself, and not imparted to it by any extraneous stimulating agency. 
The surrounding conditions may be normal, while the bladder is hypersensi- 
tive, so as to contract with undue energy by ordinary stimulation. The fault 
is in the bladder itself, whose functional activity is in excess ; this appears to 
be the most common cause of enuresis in children. It is the condition of the 
bladder which Trousseau had in mind when he wrote : " I repeat that the 
nocturnal incontinence of urine is a neurosis, and I now add that it is a neur- 
osis manifesting itself by excessive irritability of the bladder ; in fact, the 
immediate cause of incontinence is this excess of irritability in the muscular 
fibres of the bladder." As Bretonneau pointed out, children with enuresis 
from this cause habitually pass urine in a full and rapid stream, and therefore 
in less time than other children, showing that the contractile power of the 
muscular coat is in excess. From the fact that belladonna relieves so many 
patients, we infer that irritability of the muscular coat is a common cause 
of enuresis in children, since this agent acts by diminishing muscular con- 
tractility. 

5. Weakness of the muscular fibres which constitute the sphincter of the 

^ Diseases of Children, p. 257, 



ENURESIS. 869 

bladder. Diminished tonicity of the sphincter muscles does not occur, or it 
occurs very rarely in those who have had previous good health and are robust. 
Ordinarily, children affected by enuresis from this cause are in habitual ill- 
health. They have had long and prostrating sickness, which has diminished 
muscular tonicity, or they have local disease in the spine or in the course of 
spinal nerves, which has impaired the innervation of the sphincter. Some- 
times incontinence of feces is also present, and examination of the sphincter 
ani by introducing the finger shows that its contractile power is insufiicient. 
We infer the presence of atony of the sphincter vesicae from the atony thus 
easily discovered of the sphincter ani. As an example of enuresis from atony 
of the sphincter vesicae, we may mention the case of a boy of thirteen years 
who had " a flat, doughy tumor " at the lower end of the dorsal vertebrae, in 
the middle of which a deficiency in the bony arch which covers the spinal 
cord was detected by the fingers, showing that the tumor was a spina bifida 
containing a considerable amount of adipose and granulation tissue. The 
congenital deficiency in the spinal column, and consequent injury of the spi- 
nal cord, had produced incontinence of both urine and feces. 

6. We have already, in speaking of the distribution of the pudic nerve, 
alluded to the fact that enuresis in children is not infrequently produced 
through reflex action by disease or an abnormal condition external to the 
bladder in parts which receive their nerves from the same source as the 
bladder. Henoch says : " Occasionally congenital phimosis, stricture of the 
urethra, irritation of ascarides, fissure of the anus, onanism, or vulvitis can 
be detected, upon the removal of which the enuresis ceases." Trousseau 
relates the case of a young man of seventeen years who from childhood had 
been in the habit of wetting the bed two or three times every night. After 
unsuccessful trial of belladonna, strychnia, and mastich, it occurred to Trous- 
seau that the infirmity might be due to congenital phimosis, and accordingly 
Professor Jobert circumcised him. With the exception of three consecutive 
nights he was entirely relieved of enuresis during his subsequent stay of 
nine months in the hospital. In dispensary practice in New York City we 
find preputial adhesions, with the accumulation of smegma between the glans 
and foreskin, and more or less balanitis — a common cause of disturbed func- 
tion of the bladder. The dysuria and enuresis cease when the adhesions are 
divided by the probe, the smegma removed, and the preputial inflammation 
or irritation has abated. 

7. A psychical cause, to which Bartholow alludes. The patient dreams 
that he is in a convenient place for urination, the desire of which is impressed 
on his thoughts, and awakens to find that he has urinated in bed. Since the 
action of the bladder is largely under the control of the will, a strong will or 
determination, if the patient be not too sound a sleeper, does exercise a con- 
trolling action over the bladder even during sleep. We sometimes observe this 
efiect of will-power in the fact that the patient breaks the habit of enuresis 
through a sense of shame or by a determination to avoid the disgrace. Thus 
one writer mentions the case of a girl in whom severe flogging by her mother 
put a stop to the habit, and patients sleeping away from home, as when visit- 
ing among friends or at a boarding-school, sometimes break the habit through 
an eff"ort of the will. The sense of profound shame which the infirmity pro- 
duces thus enables certain patients to control the action of the bladder even 
in sleep. The state of the mind should therefore be considered as an element 
both in the causation and cure of the infirmity. 

8. Malformation of the bladder or its appendages. These are of various 
kinds. Some of them are of such a nature that cure of the enuresis is dif- 
ficult or impossible. Thus, Thomas U. Madden, M. D., F. R. S. C. E., relates 
the case of a young lady who had been treated by diff"erent physicians in 



870 DISEASES OF THE GENITO-URINARY ORGANS. 

various localities witli belladonna, iron, vesication of sacrum, and the other 
usual remedies, without the least benefit. The dribbling of urine was con- 
stant day and night, so that she was debarred from school and ridiculed and 
avoided by her associates. She was placed under chloroform, and her blad- 
der was found to have the power to retain a considerable amount of urine. 
Pursuing the examination, I)r. Madden found that the urine dribbled from a 
small orifice about half an inch above the meatus urinarius and covered by 
rugae of the mucous membrane. A No. 1 catheter was introduced its en- 
tire length through the opening, so that, in the opinion of Dr. Madden, there 
was malposition and elongation of the right ureter, which, instead of empty- 
ing into the bladder, discharged the secretion of the right kidney upon the 
vulva. In malformations like the above, as well as in ectopia vesicae, recto- 
vesical or vesico-vaginal fistula, the result of abnormal foetal development, 
the urine obviously dribbles constantly and from the moment of birth. In 
perpetual lifelong dribbling a malformation or congenital defect should be sus- 
pected, and is probably the cause. 

Prognosis. — The prognosis depends on the cause or causes of the enure- 
sis. Most of the causes are of such a nature that they can be removed, and 
the majority of patients can therefore be cured by appropriate remedies. 
Enuresis due to irritating properties in the urine, to irritation or inflamma- 
tion in the genital organs or rectum, and that due to exaggerated tonicity of 
the muscular coat of the bladder, can be for the most part readily cured 
by appropriate measures, while that resulting from structural disease of the 
spinal cord or from malformations in the urinary tract is least amenable 
to treatment. 

It is the common belief that those epochs in life which produce a decided 
change in the individual, as puberty or marriage, are likely to effect a cure 
in cases previously obstinate. This opinion is to a certain extent founded 
on fact. The development of the sexual organs at puberty seems to render 
the bladder less irritable and more retentive in some patients. Cases are also 
related, as one by Trousseau, in which incontinence ceased with marriage 
and pregnancy. But treatment in the ordinary form of enuresis should not 
be deferred in the hope that time and physical changes will effect a cure, 
for this belief is likely to be illusory. 

Treatment. — The physician asked to prescribe for a case of enuresis 
should carefully examine the patient in order to ascertain the cause. Since 
the most common cause is irritability of the bladder, whether inherent in 
the bladder itself or imparted to it by the stimulating properties of the urine, 
the urine should be rendered as bland and unirritating as possible. It should 
be made, so far as possible, as bland and unirritating as tepid water. This 
is best accomplished by rendering it neutral. Excessive acidity of the urine, 
so common a cause of enuresis, is promptly removed by the liquor potassas 
administered in doses of a few drops largely diluted. I have found it a safe 
and efficient remedy in the treatment of this infirmity when the bladder is 
unduly irritable. If, therefore, in the examination of a case we discover no 
cause of the incontinence except an exaggerated contractile power of the 
bladder, and the urine is acid, from three to five drops of the liquor potassae 
should be given, three or four times daily in a wineglassful of gum-water 
until litmus-paper shows that the urine is neutral, and its neutral state 
should be maintained. 

In belladonna we possess an agent which diminishes the functional activ- 
ity of the bladder when the latter is in excess. It diminishes the contrac- 
tile power of the muscular fibres, and its use is therefore indicated in the 
class of cases which we are now considering. In this country the tincture 
of belladonna is more commonly employed than the extract, which is used 



ENURESIS. 871 

in Europe, especially in continental Europe, and if obtained from a good 
laboratory its action is as certain as that of the extract, while its dose can be 
better regulated. Five drops of the tincture may be given every evening 
or, if the enuresis be diurnal as well as nocturnal, every morning and even- 
ing, to a child of five years, and the dose be increased by one drop every 
second day if improvement do not occur and physiological effects are not 
produced, until the dose is doubled or even trebled. If the enuresis be 
relieved, or if, without its relief, physiological effects be observed, as dry- 
ness of the fauces, cutaneous efflorescence, or dilatation of the pupils, the 
dose should not be increased. When belladonna produces the desired effect, 
it is no doubt best to continue its use for some weeks in the dose which is 
found to be effectual, and then to diminish the number of drops gradually. 

Trousseau, who, as we have seen, considered enuresis in most cases a 
neurosis, highly extolled the treatment by belladonna, believing it the most 
effectual of all methods of cure. He prescribed the extract of belladonna, 
gr. ^, or the sulphate of atropia, gr. yi-Q, but he did not state the age of his 
patients. The dose was increased if necessary, and whatever dose he found 
to give relief he administered once daily for three, four, or five months, after 
which it was gradually diminished, but it was not discontinued until after 
the lapse of two to ten months. By this treatment Trousseau states that a 
majority of his cases were signally benefited, and not a few were entirely 
relieved. The following case, which recently occurred in my practice, indi- 
cates the mode of treatment in enuresis when it results from the cause which 

we are now considering: L , aged eleven years, male, had diurnal and 

nocturnal enuresis, which seriously interfered with his comfort and rendered 
him an object of aversion and ridicule among his schoolmates. He had pre- 
viously taken belladonna and other remedies without improvement. His 
urine was found highly acid. Five drops of liquor potass^e were ordered to 
be given three or four times daily, and the tincture of belladonna, to which 
he was accustomed, was administered in nine-drop doses three times daily, to 
be increased, if need be, to fourteen or fifteen drops. The liquor potassae, 
in the dose mentioned, immediately rendered the urine neutral, and the enu- 
resis from that time ceased. The treatment recommended above, of render- 
ing the urine as little irritating as possible by neutralizing it, aided by bella- 
donna, which diminished the contractility of the muscular fibres, cured the 
infirmity, which had been most troublesome and tedious. 

If the enuresis be due to an abnormally large secretion of urine, the 
cause may be such that something can be done to relieve the patient. The 
liquid ingesta in the latter part of the day should be restricted. If it be 
found that the increased flow is due to diabetes or chronic nephritis, the enu- 
resis, though an unpleasant symptom, is comparatively unimportant, and the 
grave disease which causes it requires chief attention. The quantity of 
urine may be diminished in diabetes mellitus by the use of proper food, and 
in diabetes insipidus by ergot. 

Enuresis due to a vesical calculus is associated with symptoms, as we 
have stated above, which indicate the presence of stone, such as painful 
micturition, which may awaken the patient at night, and thus prevent the 
accident of which we are treating. Urination more frequent and painful in 
the daytime than at night, occasional interruption in the stream of urine 
from the impediment, pus, perhaps blood and an increased amount of mucus, 
in the urine, indicate the presence of a stone. Fortunately, the calculus is 
easily detected by sounding, and by the present improved instruments it can 
be crushed and removed, or it can be removed by lithotomy, which in the 
opinion of some is less dangerous, and is preferable to crushing when the 
patient is a child. 



872 DISEASES OF THE GENITO-UBINARY ORGANS. 

As we have stated above, tlie physician should always examine parts con- 
tiguous to the bladder, as the genital organs and rectum, in order to ascer- 
tain if there be any source of irritation in them which may produce irrita- 
bility of the bladder by reflex action. In some instances, as we have seen, 
enuresis rebellious to ordinary treatment ceases when the irritation in parts 
contiguous to the bladder is removed. Phimosis, preputial adhesions, the 
accumulation of smegma between the foreskin and glans, with more or less 
balanitis produced by the foul products, and vulvitis, or ascarides, should, if 
present, receive treatment, and with the removal of the irritating cause the 
enuresis will probably cease. 

Cases in which preputial irritation produces an irritable state of the blad- 
der are not infrequent among the poor of New York, whose habits are fre- 
quently degraded and filthy, and the treatment consists in dividing adhesions 
of the glans to the foreskin, cleaning away the smegma, and using a sooth- 
ing ointment. The foreskin can, with few exceptions, be sufficiently stretched 
for this purpose, so that incision (or circumcision, which is frequently per- 
formed in these cases) is unnecessary. 

If the enuresis be due to atony of the sphincter, a remedy is required 
which acts very differently from belladonna. If weakness of the sphincter 
be the cause, the indication is obviously to increase its tonicity, and the two 
medicines which have been most successfully employed for this purpose are 
nux vomica (or its active principle strychnia) and ergot. We have stated 
that the sphincter is more abundantly supplied with nerves than is the mus- 
cular coat of the bladder, so that those agents which restore innervation, and 
thereby increase muscular tonicity, act upon the sphincter more powerfully 
than upon the muscular coat. Ergot appears to exert a similar action, 
though perhaps less in degree, upon the sphincters of the bladder and anus, 
to that which it exerts upon the uterine muscular fibres. 

We can obtain a clearer idea of the eifect of therapeutic agents upon 
paresis of the sphincter vesicae by observing their action in paresis of the 
sphincter ani, for these two sphincters suffer a loss of power from the same 
causes, and recover it by the use of the same agents. 

In a very instructive paper on incontinence of feces, published by Dr. 
George B. Fowler in the American Journal of Obstetrics for October, 1882. 
two cases are detailed, showing unmistakably the beneficial action of ergot in 
increasing the tonicity of the sphincter ani ; and the same treatment is indi- 
cated for urinary incontinence when it arises from a similar cause. A child 
of seven years, in the practice of Dr. Fowler, had been closely confined to 
his studies, with probably some deterioration of his health, when fecal incon- 
tinence commenced. The tonicity of the sphincter ani on examination with 
the finger did not seem much impaired. Nevertheless, it was so increased by 
ten-drop doses of the fluid extract of ergot that the incontinence was relieved. 
The second patient, an anaemic girl of thirteen years, had been under treat- 
ment with iron and other tonics without benefit to the fecal incontinence. 
Her flesh was flabby and surface cool, and, which is interesting to remark as 
throwing light on the condition of the vesical sphincter when it lacks toni- 
city, a lack of resistance in the anal outlet was very apparent to the touch. 
A mixture containing 15 minims of the fluid extract of ergot and grain yi-g- 
of strychnia was given three times daily. At the end of the first week she 
had only two recurrences of the trouble, and in three weeks was cured. 
Four months afterward, although she had been taking quinine and iron after 
the discontinuance of the ergot, a partial relapse occurred, and a suppository 
of five grains of ergotin, with butter of cocoa, was employed morning and 
evening. Immediate relief followed, the tonicity of the sphincter was 
restored, and the suppositories were discontinued after two weeks. The 



ENUEESIS. 873 

beneficial effects of ergotin in weakness of tbe sphincters is shown by these 
cases. Enuresis from weakness of the sphincter vesicae could not have been 
better treated than by the same remedies which relieved the fecal inconti- 
nence in these two patients. 

A considerable number of medicines which are now seldom used have 
been employed with more or less success for enuresis. According to 
Bouchut, M. Ribes was the first who prescribed nux vomica. The 
patient was a soldier who had both urinary and fecal incontinence, and 
was cured of the weakness of the bladder in five days. Nux vomica is 
employed instead of strychnine, as its use involves less danger. Mon- 
diere prescribed this agent in combination with the black oxide of iron 
in the following formula : 

R. Extracti nucis vomicae, gr. vj ; 
Ferri oxidi magnetici, 3J- 

Ft. pil. No. xxiv. Take one pill three times daily. 

Although we accept the statement of Bouchut that strychnia is an 
"extremely dangerous" remedy for enuresis if the patient be under the 
age of four or five years, yet over that age it can be safely prescribed as 
an adjuvant to the ergot in proper dose and with proper precautions. A 
small dose, repeated after three hours, is obviously safer than a larger dose 
at longer intervals. 

Among the remedies not yet mentioned which have been successfully 
employed in certain cases, the tincture of cantharides requires notice. In 
large doses this drug causes strangury, but in small doses it produces 
such irritation or stimulation of the surface of the urethra as to increase 
the contraction of the sphincter and awaken the patient when the urine 
presses upon the urethral orifice, which is rendered sensitive by this a^ent. 
Cantharides is an unpleasant remedy, and it is not much employed of late 
years ; probably the benefit from its use is not usually permanent. A child 
of five years can take four or five drops, largely diluted with water, three 
times daily, and the dose should be gradually increased until there is some 
evidence of its effect on the outlet of the bladder. 

Cubebs, recommended by M. Dieters, the various vegetable tonics and 
astringents, iron, creasote, and many other remedies, have fallen into dis- 
repute and are now seldom used. Sometimes certain combinations of rem- 
edies give prompt and entire relief. Eustace Smith says : " I have lately 
cured a little girl, aged four years, who had resisted all other treatment, with 
the following draught, given three times daily : 

" R. Tinct. bellad,, ^j; 

Potas. bromidi, gr. x; 

Infus. digitalis, ,^ij ; 

Aquse, ad ^ss. Misce. 
Ft. haustus." 

The tincture of belladonna of the British Pharmacopoeia has about half 
the strength of that employed in the United States ; but even with this 
allowance I would not dare to prescribe so large a dose of this agent, 
except that smaller doses were first used and tolerance of the remedy 
demonstrated. Of the tincture of belladonna of the U. S. Pharmacopoeia 
ten minims would be a large dose. 

Local treatment has been attended by a degree of success. The neck of 
the bladder and the urethra have been cauterized by the nitrate of silver 
applied by the porte-caustique of Lallemand, with some relief of the enure- 
sis, at least so long as the soreness remained. Baths and douches of cold 
water have also been used by many physicians, some of whom, as Under- 



874 DISEASES OF THE GENITO-URINARY ORGANS 

wood, Baudelocque, Guersant, and Dupuytren, state that they have obtained 
good results. This treatment is most beneficial in those cases in which the 
sphincter is relaxed. 

Finally, in certain patients the advice of Trousseau may be followed, that 
the patient in the daytime resist the inclination to pass urine so long as it 
does not greatly increase his or her discomfort ; by this means greater toler- 
ance of the presence of urine in the bladder is produced. 

Calculi; Dysuria; Cryptorchia. 

We have seen, in our remarks on Uric- Acid Infarctions, how calculi may 
form in the pelvis of the kidney, first as small concretions, and how, descend- 
ing to the bladder, they may become nuclei which gradually increase by 
accretions to their surfaces, or they may form primarily in the bladder. A 
vesical calculus is not very infrequent, even in the young child. Its pres- 
ence is manifested by dysuria and increase of mucus, and the occurrence of 
pus and sometimes of blood-cells in the urine. Occasionally the flow of 
urine is obstructed by the presence of the calculus, and the consequent 
tenesmus causes prolapsus ani. Prolapsus ani and dysuria are important 
symptoms of stone in the bladder. Sometimes the bladder becomes greatly 
distended with urine, and there may be trickling of it, with oedema and sore- 
ness of the prepuce and adjacent parts. Now and then a calculus lodges in 
the urethra, producing more or less retention of urine, with oedema of the 
prepuce and adjacent parts. The treatment for calculus must be entirely 
surgical. Lithotrity as now performed with improved instruments is devoid 
of danger and successful. If a stone lodge in the urethra, it is usually near 
its outer extremity, where the canal is narrowest, and it can be removed by a 
pair of small forceps. 

Dysuria occurs from various causes. It not only results from calculus, 
but also from urine concentrated and acid. We have stated above that urine 
containing uric acid and the urates, if they are abundant, is highly irritating, 
and while this acid and its salts increase the frequency of micturition, they 
are likely to render it painful. They sometimes cause colicky pain from 
spasmodic contraction of the muscular fibres in the urinary tract, and even 
transient albuminuria has been noticed. Dysuria from this cause is best 
treated by alkaline and mucilaginous drinks. 

Dysuria not infrequently arises from a morbid state of the external gen- 
itals, and they should always be examined when micturition is painful or 
obstructed to ascertain their condition. In the first two or three years of 
life the prepuce is usually adherent to the glans through epidermal cells, 
which appear to arise from the rete Malpighii, and instead of becoming horny 
remain soft and filled with protoplasm. This adhesion is so common that it 
must be considered normal, especially as it does not give rise to s3miptoms. 
But occasionally, even in young boys, a pathological state sometimes occurs 
which gives rise to symptoms, among which is dysuria. Phimosis may be 
present, retarding the flow of urine, some of which is retained under the 
foreskin, where, decomposing, it excites balanitis, causes adhesions, and renders 
urination painful. Circumcision gives relief to the local disease and the 
dysuria. In the Out-door Department at Bellevue Hospital, where a con- 
siderable number of cases of this kind have been brought for treatment, it 
has rarely been necessary to circumcise or slit the prepuce. Instead of this, 
the adhesions are divided by a probe, the prepuce stretched and drawn back 
so as to expose the glans, and the parts thoroughly smeared with a simple 
ointment ; if there be much inflammation and swelling, it may be necessary 
to etherize the patient for the operation. 

In young girls the labia minora are often adherent, apparently through a 



VULVITIS. 875 

catarrhal inflammation. They can, for the most part, be readily separated by 
traction, when minute drops of blood appear upon the exposed surfaces, show- 
ing that a vascular connection has already occurred. Henoch^ says: "In a 
few cases this adhesion appears to me to be the cause of dysuria, which dis- 
appeared after the separation of the labia from one another; in others exam- 
ination showed inflammatory redness of the introitus and meatus, with 
increased secretion of mucus, which renders the excretion of urine pain- 
ful." Separating the adherent parts and covering the surface with simple 
ointment to prevent readhesion sufiice to efi"ect a cure of the dysuria when it 
depends upon this cause. 

In the first months of foetal life the testes lie in the abdominal cavity in 
front of and a little below the kidneys, behind the peritoneum, and attached 
to the base of the scrotum by a long cord, the gubernaculum testes. Between 
the fifth and sixth months the testes descend to the iliac fossa, with corre- 
sponding shortening of the gubernaculum. At the end of the eighth month 
it has descended into the scrotum, surrounded by a pouch of the peritoneum, 
which becomes detached from the peritoneum "just before birth" (Gray), 
forming a closed sac, the tunica vaginalis. It is estimated that in one case 
in five the descent of the testicle is delayed from a few months to a year 
after birth. Astley Cooper states that the descent does not occur in some 
cases until between the thirteenth and seventeenth years. When there is 
this late descent intestine is apt to follow the testicle, causing inguinal 
hernia. In about one case in one thousand, it is estimated, the testicle 
does not descend, but remains in the abdominal cavity, either on account of 
adhesions to the abdominal viscera, the small size of the ring, or some defect 
in the gubernaculum. Occasionally, a retained testicle has the normal struc- 
ture and development, but, as a rule, it is imperfect and small, like the tes- 
ticle of the infant, and it is prone to fatty or fibrous degeneration. If both 
testicles are retained, impotence may result on account of the non-develop- 
ment or degeneration. No treatment is required for the retained testicle, 
unless it become inflamed when lying in the inguinal canal, when it should 
be treated by poultices and other soothing remedies. 

Vulvitis. 

Inflammation of the vulva is common in girls under the age of five years- 
Like most other inflammations, it varies in severity in diff'erent cases, from a 
mild and transient attack to one attended by tumefaction and excoriation or 
ulceration of the labia, pain, and abundant discharge. Ordinarily, when the 
physician is consulted, the disease has continued a few days, and he finds the 
vulva moist from a muco-purulent discharge, which dries into light yellow 
■crusts and produces greenish or yellowish stains on the under-clothes. The 
Tulva and lower part of the vagina are sensitive and red, and the acrid secre- 
tions sometimes cause redness of the skin over which they flow. Frequently 
the labia are swollen and tender, the patient may complain of soreness from 
friction in walking, and sometimes dysuria occurs from extension of the 
inflammation into the urethra. In severe cases ulcerations or erosions upon 
the labia result, increasing the distress of the patient. 

Vulvitis is sometimes aphthous. Small rounded elevations appear upon 
the vulva and ulcerate, and the adjacent surface is red and more or less 
swollen. The ulcers are sensitive and painful, but under ordinary circum- 
stances they progressively heal. Rarely, in those who are markedly cachec- 
tic the ulcers become gangrenous and recovery is tedious and uncertain. 

Etiology. — The most common cause of vulvitis appears to be uncleanli- 

^ Diseases of Children, 1882. 



876 DISEASES OF THE GENITO-URINABY ORGANS. 

ness, and hence its frequency in the families of the poor and degraded in 
cities. The collection of dirt and sebaceous matter upon the vulva, and the 
irritation to which it gives rise, which prompts the patient to rub or scratch 
the parts, cause inflammation. Struma strongly predisposes to this inflamma- 
tion, so that slight irritating causes develop it in those who possess this diath- 
esis. K considerable proportion of those who have vulvitis have or have 
had other manifestations of scrofula and present the strumous aspect, so that 
it seems proper to consider the inflammation of the vulva occurring under such 
circumstances as possessing a strumous character or as a local manifestation of 
the strumous diathesis. We therefore, with Dr. West, regard struma as an 
important predisposing cause of vulvitis in the child. Ascarides in the rectum 
have long been recognized as a cause, producing this effect by the intense 
itching which prompts the patient to rub the parts and thereby inflame them. 
It is said that ascarides sometimes crawl to the vulva, and produce inflamma- 
tion by their presence upon the sensitive surface. A last and most important 
cause is infection by gonorrhoeal pus. Every physician who sees cases in the 
dispensaries or tenement-houses of our large cities meets cases, even girls of 
three or four years, in whom vulvitis has this cause. Sometimes the gonor- 
rhoea is communicated criminally ; in other instances it is contracted from 
the infected seat of a privy or from soiled towels or linen. A young man 
whom I attended was under treatment for gonorrhoea, when his two nieces 
of about four and six years were infected by the same disease, probably from 
soiled towels. The anatomical characters do not enable us to discriminate 
between gonorrhoeal and non-specific vulvitis, but the diff"erential diagnosis 
may be made by observing the gonorrhoeal microbe in the secretions of the 
one and its absence in those of the other. In both forms of vulvitis the 
mucopurulent secretion and the inflammatory lesions are identical. The 
danger of infecting the conjunctiva and producing purulent ophthalmia from 
inoculation with the secretion of vulvitis is well known. On the other hand,, 
it is believed by some that vulvitis is occasionally caused by inoculating the 
vulva with the muco-pus of ophthalmia. 

Treatment. — The parts should be frequently bathed with tepid water or 
mucilaginous water to ensure complete cleanliness. This, with the use of a 
mild astringent employed with a syringe, suffices in most instances to produce 
immediate improvement, and in a few days to effect a cure. Vaginal injec- 
tions of tannin or alum (5 : 100), sulphate of zinc (2 : 100), or nitrate of 
silver (1 : 100) have been employed with good result in this disease. I 
have obtained benefit from the following mixture, and more frequently rec- 
ommend it than any other: 

R. Zinci snlphat., ^ss; 

Plumbi acetat., ^j ; 

Tinct. opii, 

Tinct. catechu, da. f^iij ; 

Aquse, ad f^iv. Misce. 

To be injected warm four or five times daily through a small glass or gutta- 
percha syringe. The same should be applied with a camel's-hair pencil to- 
the external parts. The following are also useful formulae : 

R. Ext. opii aq., ,^j ; 

Liq. plumbi subacetat. dil., f Jiv. Misce. 

R. Pulv. zinci oxid., .!^j ; 

Acidi tannic, i)']\ 

Mucil. acacise, f^ss; 

Aq. rosse, f^iiiss. Misce. 

If ascarides be present, a cold rectal enema of lime-water or salt and 
water should be used daily. Benefit may be obtained from rectal enemata of 
simple cold water even when ascarides are not present. 



SECTIOE^ V. 

SKIN DISEASES. 



CHAPTEK I. 

ERYTHEMATOUS DISEASES. 

Under this head are included erythema, roseola, and urticaria. They 
consist in active congestion — inflammatory, it is believed — of the skin, which 
soon declines, with or without slight furfuraceous desquamation. The color 
of the affected cuticle is bright red in erythema, rosy in roseola, and pale red 
in urticaria. Febrile symptoms often precede for a few hours the occurrence 
of the eruption, and they abate as it appears. 

Erythema. 

The eruption of erythema occurs in patches of diiferent sizes, the largest 
ordinarily not exceeding four or five inches in diameter, and most of them have 
considerably smaller dimensions, their margins being in some instances dif- 
fused, and in others circumscribed and well defined. The patches are slightly 
swollen from engorgement of the capillaries of the skin and slight serous 
effusion, and are accompanied by a sensation of heat and itching. 

Erythema is idiopathic or symptomatic. The idiopathic form is subdivided 
into erythema simplex, intertrigo, and laeve. Erythema simplex is produced 
by external agencies of an irritating nature, as heat, cold, friction, chemical 
and mechanical irritants, applied to the skin. A common example of this 
form of the disease is the efflorescence about the anus in cases of infantile 
diarrhoea, due to the acidity of the evacuations. Erythema intertrigo is pro- 
duced by the friction of opposing surfaces of the skin, and it therefore occurs 
mainly in the folds of the neck, about the groins, and behind the ears. This 
inflammation is sometimes slight, disappearing in two or three days with 
proper treatment ; in other cases the epidermis becomes denuded, the surface 
is tender and moist, and even superficial excoriations occur. In severe cases 
the ulcers extend more deeply and give rise to considerable purulent discharge, 
the skin and even subcutaneous connective tissue being more or less infil- 
trated and indurated. The confinement of the perspiration, and the moist- 
ure which is exuded between the folds of the skin, increase the inflammation. 
The effused liquid does not in ordinary cases stiffen linen, as in eczema. Ery- 
thema laeve is the name applied to the inflammatory hyperaemia of the skin 
which often occurs over oedematous parts. Its most common seat is about 
the ankles and upon the legs. In children it is most frequently observed in 
the oedema which results from scarlatinous nephritis and from heart disease. 

Si/mptomatic erythema, which occurs from a general or constitutional 
cause of a pyrexia! character, has several subdivisions. The simplest and 

877 



878 ERYTHEMATOUS DISEASES. 

mildest form of it is erythema fugax, which comes and goes quickly. The 
erythema which appears upon the features in acute meningitis is a typical 
example. It is common in various inflammatory and febrile affections. If 
the erythematous patch be circular, with normal skin in its centre, it is 
sometimes designated erythema circinatum and, if the margin be well defined, 
marginatum. Erythema papulatum, tuberculatum, and nodosum are applied 
to the same form of the disease, one or the other term being employed accord- 
ing to the stage or size of the eruption. In erythema papulatum the eruption 
begins as small red spots, which soon become papular and attain a size vary- 
ing from that of a pin's head to a split pea. It occurs especially on the neck, 
breast, arm, and back of the hand, and fades away, with slight desquama- 
tion, in about three weeks. In erythema tuberculatum and nodosum the 
eruptions have a greater diameter and are usually more prominent. In 
the latter variety they often have a diameter of two or more inches, and 
occur most frequently upon the anterior aspect of the leg. These three forms 
of erythema, which may be described as one, occur chiefly in young people. 
Erythema tuberculatum is most common in servants, especially those recently 
from the country. The tumefaction is due to the effusion of serum in the 
corium, and, when the eruption has considerable prominence, also in the sub- 
cutaneous connective tissue. The color is at first a bright red, then dark red 
or purple, and it fades away like the discoloration of a bruise as the eruption 
declines. Rheumatism is often, and diarrhoea occasionally, associated with 
these forms of erythema, and rheumatic pains are occasionally present, as 
well as more or less fever. 

Prognosis. — This, as regards the erythema, is always good. An unfavor- 
able result in any case is due to cachexia or some coexisting disease. The 
duration of the milder cases is only a few hours, while cases of a more severe 
type, as erythema nodosum, last two or three weeks. 

Diagnosis. — The ordinary forms of erythema are distinguished from ery- 
sipelas by the absence of any very decided burning pain and tumefaction of 
the integument and tendency to spread, and by less marked constitutional 
symptoms. In those cases of erythema in which there are infiltration and 
swelling of the skin and subcutaneous connective tissue, the patches are dis- 
tinguished from those of erysipelas by being multiple, of small size, less hot 
and painful, not extending, and presenting as they disappear the phenomena 
of a bruise. In urticaria the wheals, that come and go suddenly with a pecu- 
liar stinging sensation, and the irritability of the skin in consequence of whicK 
these wheals are produced by slight friction, differ so much from the symp- 
toms and appearances of erythema that the differential diagnosis of the two is 
easy. In roseola the eruption ordinarily occurs over a large part, if not the 
entire surface, in points and small patches with healthy skin between, and 
presenting a rosy instead of a bright-red color — characters which sufficiently 
distinguish it from erythema. Erythema when extensive is sometimes mis- 
taken for the scarlatinous eruption, but the redness of the fauces, graver 
constitutional symptoms, vomiting, persistence of the eruption, etc. serve to 
distinguish the latter from the former affection. In cases of doubt it is 
proper to defer the diagnosis for a day or two, when if the rash be erythe- 
matous it will fade. Erythema sometimes occurs in the initial stage of vari- 
ola, when, on account of the grave general symptoms, it may be mistaken for 
scarlatina. I have more than once known this mistake to be made in the 
hurried visits of the physicians in former times, when smallpox was more 
common than at present. A more careful examination would prevent this 
error. There is little danger of confounding erythema with measles or the 
various papular, vesicular, or pustular skin diseases. 

Treatment. — Erythema fugax requires no special treatment, except 



ROSEOLA. 



879 



occasional dusting the surface with lycopodium or powdered starch. Those 
forms of erythema which are due to mechanical or chemical irritants soon 
disappear when the cause is removed. In erythema around the anus, pro- 
duced by the irritation of the urinary and alvine evacuations, the diaper 
should be changed as soon as soiled, and if the stools be frequent and acid 
the alkaline treatment proper for the diarrhoea is useful also for the erythema. 
In ordinary erythema, as well as in erythema intertrigo, the following pre- 
scriptions for external use will be found beneficial : 



Or, 



R. Zinci oxidi, 

Pulv. calaminse praep. 

Glycerinse, 

Liq. calcis, 



R. 



Lycopodii, 

Pulv. bismuthi subnit., 



Biv; 

5ss; 



Misce. 



R. Pulv. zinci oxidi, 
Lycopodii, 
To be frequently dusted upon the inflamed surface. 

Or, 

R. Acidi salicylici, 

Bismuthi subnitratis, 
Corn starch, 
Ung. aqua? rosse, 



Jiss. Misce. 



^iss. Misce. 



gr. v; 

3i) ; 

.^iss; 

5J. Misce. 



In obstinate cases the application three or four times daily of diluted 
lotio nigra will frequently be followed by immediate improvement. 

Potassium chlorate internally, to correctthe acidity of the transpiration 
from the skin in protracted and obstinate cases, and in certain instances cod- 
liver oil and the syrup of iodide of iron, are called for. If the derangement 
of the system upon which the erythema depends appears to be of a rheu- 
matic character, the sodium salicylate or alkalies may be required. Ery- 
thema papulatum, tuberculatum, and nodosum occur most frequently in 
reduced states of the system, and therefore need tonics. 

Roseola. 

The term " roseola " is applied to rose-colored spots or patches of greater 
or less extent, accompanied by a degree of febrile reaction and often by red- 
ness, with little or no swelling of the faucial surface. It is attended by a 
sensation of warmth and slight itching. The following groups and sub- 
divisions embrace the recognized varieties of this disease : 



EOSEOLA. 
Idiopathic. Symptomatic. 

Infantilis. Variolosa. 

jEstiva. Vaccinia. 

Autumnalis. IMiliaris. 

Annulata. Pheumatica. 

Punctata. Arthritica. 

Cholerica. 

Febris continuse. 

Syphilitica. 

The color of the eruption gradually fades from a rose-red to a duller hue,^ 
and often disappears in two or three days. In other instances the eruption 
lasts a week or more. Roseola may occur in any season, but it is most com- 



880 ERYTHEMATOUS DISEASES. 

mon, especially the idiopathic form, in the warm months. Those varieties of 
the idiopathic disease which are designated infantilis, aestiva, and autumnalis 
are the most common in early life. They are in reality identical or nearly so, 
and may be described as one disease. 

Symptoms. — Roseola infantilis, asstiva, or autumnalis may be partial, 
appearing upon the arms and legs, or general. It is often preceded by fever, 
languor, and, in those old enough to describe their sensations, by pain in head, 
back, and limbs. There is a great difference, however, in different cases as 
regards the severity of the prodromic symptoms. They may be absent or 
so slight as scarcely to be appreciable. Occasionally vomiting, diarrhoea, 
or other symptoms of derangement of the digestive apparatus immediately 
precede the eruption. 

The eruption of roseola, when general, usually commences upon or about 
the neck and face, and in the course of twenty -four to thirty-six hours appears 
upon the rest of the surface. It bears considerable resemblance to that of 
measles. The patches are irregular in shape, a quarter to half an inch in 
diameter, and, though of a rose color at first, they soon present a dusky hue 
as they begin to fade; by pressure the redness disappears. In the majority 
of cases the eruption has nearly faded by the fifth day. The redness of the 
faucial surface, together with the itching or tingling, disappears with the sub- 
sidence of the rash. 

Roseola annulata is a rare disease. It commences with constitutional 
symptoms, which are slight or pretty severe, and which cease when the erup- 
tion appears ; this occurs in the form of red circular spots, which enlarge to 
the diameter of an inch or thereabout, and assume the shape of rings enclosing 
healthy skin. The rash fades in a few days, often leaving a bruised appear- 
ance. The ordinary location of this form of er3^thema is upon the abdomen 
and about the thighs. In roseola punctata the eruption is of small size, and 
it occurs upon a large part of the surface. 

Symptomatic roseola, which appears in the course of various diseases, 
need only be alluded to. The diseases in which it is developed are, with the 
exception of syphilis, chiefly of an acute febrile or inflammatory character. 
This eruption is often really, as stated by Tilbury Fox, a rose-colored ery- 
thema, but in other instances it presents the typical form and appearance of 
roseola. Thus I have known it to occur about the eighth or ninth day of 
vaccinia in rose-colored spots over the whole surface, and producing much 
anxiety on the part of parents lest impure virus had been employed. 

Causes. — These are in a measure obscure. The delicacy of the skin in 
infancy and the active cutaneous circulation no doubt predispose to roseola 
and erythema, and hence the frequency of their occurrence in acute febrile 
and inflammatory affections. Summer weather, with the derangements of 
system which it produces, has been in my experience the most frequent cause 
of idiopathic roseola in young children in this city. In certain summers, as 
in that of 1868, a large proportion of the infants have been affected by it, 
and I have been led to consider it a favorable prognostic sign as regards the 
diarrhoeal affections which are so common in the warm months. 

Prognosis. — Roseola is always a mild and favorable disease. 

Diagnosis. — Roseola is distinguished from measles by the absence of 
catarrhal symptoms, a less degree of fever, less uniformity in the size of the 
eruption, and the absence of the history of contagion. Roseola is distin- 
guished from erythema by the smaller size of the eruption and its rosy or 
dusky-red color. The boundary-line, however, between the two diseases is 
not well defined, and certain forms of roseola may be described as erythema. 
The general but punctiform efilorescence, increase of temperature, acceleration 
of pulse, and the peculiar appearance of the tongue and fauces, serve to dis- 



URTICARIA. 881 

tinguish scarlet fever from roseola. There is little danger of confounding 
roseola with urticaria, since the wheals of the latter appear in no other 
disease. 

Treatment. — This is simple. If roseola occur in connection with gastro- 
intestinal derangement or disease, the remedies which relieve the latter exert 
a curative effect upon the former. In all cases the state of the system should 
be inquired into, and any departure from a state of health corrected. Roseola 
needs no further constitutional treatment. If there be itching or tingling of 
the surface, a lukewarm lotion, containing equal parts of liq. amnion, acetat. 
and mistura camphorae, has been recommended, or a lotion containing a 
drachm of hydrocyanic acid to a pint of an emulsion of bitter almonds, used 
warm. The purpose of such lotions is simply to relieve the unpleasant sen- 
sation. Cold applications or others which would repel the eruption should be 
avoided ; such an effect might be injurious. In case of acidity of stomach 
alkaline remedies are useful, and in certain cases tonic treatment is indicated. 

Urticaria. 

The name by which this disease is designated is derived from the term 
urfica, the nettle, the sting of which produces this form of eruption. The 
eruption occurs suddenly in wheals or pomphi, attended by tingling and 
burning, and suddenly disappearing. Urticaria is often accompanied by no 
very decided general symptoms, but in some patients more or less fever 
and lassitude occur, with perhaps epigastric pain and headache. The wheals 
may occur over the whole body, but more frequently are confined to a por- 
tion of it. Their shape may be round, oval, irregular, or band-like, and their 
length varies from a few lines to several inches. In one affected by urticaria 
the wheals can be readily produced by scratching or rubbing the surface. 
The eruption is thus clearly described by a recent writer : " At first a bright 
flush appears; the centre of this becomes slightly elevated and pales, hence 
appears of lighter color ; the tint may be rosy, but more generally it is 
whitish." The margin of the wheal, the diameter of which varies, always 
remains red. This eruption appears to be produced by active congestion of 
the cutaneous capillaries, some serous effusion, and spasm of the muscular 
fibres of the skin. The effusion of serum in certain localities is quite appar- 
ent from the oedema which occurs. The subsidence of the eruption is with- 
out desquamation. Urticaria is ordinarily an acute disease. It is some- 
times chronic in the adult, but rarely so in children. Several varieties of 
it are described by dermatologists, according to the cause, appearance, and 
duration. 

Causes. — These are external and internal. Various irritants apart from 
the nettle applied to the surface produce the wheals, as the bites of certain 
insects and sometimes turpentine. The following are the principal internal 
causes, as summarized by Hillier: 1st, profound and sudden mental emotion ; 
2d, certain articles of diet, as shell-fish, pork, sausage, cheese, etc. ; 3d, cer- 
tain medicinal substances, as copaiba, valerian, and turpentine ; 4th, intes- 
tinal worms, though it is probable that these seldom operate as a cause ; 
5th, uterine ailments, as hysteria. 

Prognosis ; Diagnosis. — The prognosis is good, though the chronic 
form is sometimes tedious and troublesome. The occurrence of the wheals 
and the possibility of producing them by friction serve to distinguish this 
•disease from all others. 

Treatment. — In urticaria due to recent ingesta of an irritating or 
indigestible character an emetic of ipecacuanha is useful, followed by a 
saline, and better also an alkaline aperient, as Rochelle salts. An aperient 
of this kind is useful ordinarily in acute cases attended by febrile reaction. 

56 



882 PAPULAE DISEASES. 

The diet for several days should be simple and such as is readily digested, as 
fresh beef, bread, or other farinaceous food, and milk. Occasionally the 
wheals appear periodically, when a few doses of quinine effect a prompt cure. 
After the above measures have been employed the subsequent treatment, 
whether tonic or otherwise, depends on the condition of the patient. Little 
benefit accrues from local measures. Sponging the surface with cool water 
to which a little vinegar is added relieves, in a measure, the heat and ting- 
ling of the wheals. 



CHAPTER II. 

PAPULAE DISEASES. 
Strophulus. 

The three papulae — namely, lichen, prurigo, and strophulus — which are 
characterized by small and firm elevations upon the skin, occur in children ; 
but the two former are not common, and as they do not differ in any essen- 
tial particular from the same diseases in the adult, they will not be treated 
of in this connection. Strophulus, on the other hand, is a disease peculiar 
to children. It is known as the red gum or white gum according to its 
appearance, and also as the tooth rash. The eruption appears usually on 
parts which are exposed, as the face, neck, and extremities, the papules being 
in some patients of the size of, or even smaller than, a pin's head, while in 
other cases they are as large as a millet-seed. 

The varieties of strophulus described by dermatologists are : 

S. intertinctus, S. candidus, 

" confertus, " volaticus, 

" albidus, " pruriginosus. 

The following are the characters of these varieties : S. intertinctus, pap- 
ules bright red, and occurring chiefly upon the cheeks, forearm, and back of 
hand ; often intertinctured with blushes of erythema ; it lasts from two to 
four weeks and is most common in young infants. S. confertus, papules 
numerous and closely aggregated, paler, continuing longer than in strophu- 
lus intertinctus, and likely to recur, appearing about the time of dentition, 
and most frequently upon the arm. Sometimes certain of the patches 
become chronic, slowly disappearing and leaving the skin rough and dry. 
S. volaticus appears usually upon the arms and cheeks in patches of about a 
dozen (fewer or more) papules, which soon disappear. These patches reap- 
pear at intervals for two or three weeks, and are attended by heat and itch- 
ing, though not intense. S. albidus, so called, should really be placed among 
the diseases of the sebaceous glands and described under another name. It 
appears in the form of small white elevations as large as a pin's head, com- 
monly upon the face and neck, and produced by distension of the sebaceous 
glands with the secreted product. The term strophulus candidus is applied 
to large white papules which appear upon the sides of the trunk, shoulders, 
and arms of infants of one year or thereabouts, and disappear in about one 
week. They are liable to be associated with the papules of strophulus con- 
fertus. S. pruriginosus is really a form of lichen, occurring chiefly above 
the age of one and under that of eight or nine years. The papules, which 



ECZEMA. 883 

are small and discrete, usually appear over a large extent of surface, ordi- 
narily upon the back, front of the chest, the face and arms, and as they are 
scratched from the itching, minute dark points of blood collect and dry upon 
their apices. This form of strophulus is more protracted than the others, 
and, in consequence of the irritation produced by the scratching, pustules 
of ecthyma often occur among the papules. The apparent cause of stroph- 
ulus pruriginosus is a mode of life which impoverishes and vitiates the 
blood, such as uncleanliness and residence in damp, dark, overheated, and 
overcrowded apartments. Atmospheric heat also operates as a cause of this 
form of strophulus, and it is not an infrequent disease in cities during sum- 
mer months. 

The various eruptions included under the term " strophulus " have such 
different anatomical characters that a proper classification would locate some 
of them in other groups of skin diseases. One form of it, as we have seen, 
is produced by distension of the sebaceous glands ; in other, and the majority 
of cases, as appears from the recent observations of Mr. Fox, its seat is the 
sweat-glands, and in others still the papillary layer of the skin, as in lichen, 
the papules being produced by an exudation. 

Treatment. — Personal cleanliness, with frequent change of linen and 
daily ablution without the use of soap, should be enjoined. Local irritants, 
which might aggravate or cause the disease, should, so far as practicable, be 
removed. Alkalies in cases of acidity of the jyrlmse viae.^ and occasionally 
mild aperients, are required ; the food should be bland but nutritious, and if 
the child be nursing it may be necessary to attend to the health of the wet- 
nurse. Favorable hygienic conditions, important for the successful treatment 
of all forms of strophulus, are especially required in strophulus pruriginosus. 
Nutritious diet, fresh air, quinine, iron, cod-liver oil, etc. should be prescribed 
for those affected by it. In strophulus albidus the small round, whitish, 
sebaceous elevations should be opened by the point of a lancet and their 
contents pressed out between the thumb-nails or by pressure with a watch- 
key. 



CHAPTER III. 
ECZEMA. 

This is one of the most common maladies of the skin. It constituted 
one-third of Devergie's cases and one-sixth of Hillier's. In the commence- 
ment of the eczematous eruption the skin presents a superficial redness, and 
upon this inflamed area numerous minute and closely aggregated papules, 
vesicles, or, more rarely, pustules, appear. These are very fragile, so that 
they soon rupture, the epidermis is broken and destroyed, and the surface is 
moistened by an effusion which appears to be serum, and cannot be distin- 
guished from it by the microscope. This liquid when dry stiffens linen. As 
it dries thin crusts form of a light-yellow color upon most parts of the sur- 
face, but they are thicker and of a deeper yellow color upon the scalp than, 
elsewhere. The crusts consist mainly of pus, epithelial cells, and granular 
matter. 

Anatomy. — Biesiadecki has described the formation of the eczematous 
eruption. According to him, the papules are produced from the papillae, 
which increase in size by cell-formation in their interior. The connective- 



884 ECZEMA. 

tissue corpuscles enlarge, and are unusually " rich in fluid," and their num- 
ber increases. Under the microscope spindle-shaped corpuscles are observed, 
filling the papillae, and extending up from them into the rete Malpighii, 
crowding apart the cells of this layer and reaching and elevating the epi- 
dermis. The epithelial cells in the immediate vicinity of the papilla? also 
become swollen. This cell-growth produces the eczematous papule. 

If the cell-formation continues within a papilla, certain of the cells are 
ruptured, and as they are very moist a liquid is effused which raises the epi- 
dermis over the summit of the papilla. This produces the eczematous ves- 
icle. Occasionally pus mixes with this liquid, and the eruption is then ves- 
ico-pustular. 

In acute eczema the upper part of the true skin is infiltrated and swollen, 
tvhile the lower part is commonly unaffected, except in the most severe cases. 
The older the eczema the greater the extent of the infiltration, so that in 
chronic eczema the whole thickness of the skin is more likely to be involved 
than in acute forms of the malady. The discharge of the eczematous sur- 
face is irritating, and healthy skin with which it may come in contact is often 
reddened by it and made eczematous from its irritating efi"ect. This eczema, 
occurring upon a part of the surface which is in contact with an opposite 
surface of sound skin, commonly affects the latter, and, as Neumann has 
stated, a nurse by carrying an infant having eczema upon its nates may con- 
tract the same disease upon her arm, although there is no contagious prin- 
ciple in this malady. 

Etiology. — Eczema is often produced by irritating substances applied to 
the skin. Croton oil, certain soaps, the finger-nails in scratching, a hat, truss, 
or belt by pressure, may produce it. Those having a tender and delicate skin 
are more liable to it than others. The constitutional causes are often obscure. 
It is sometimes obviously due to indigestion or a diet which disagrees, for we 
see it occur in nursing infants as a result of sickness of the mother. Anae- 
mia and scrofula are occasional causes. Among the city poor eczema is com- 
mon, and many of the children who have it are scrofulous, but a large pro- 
portion show no evidence of struma, and in the better classes of society a 
majority do not. 

Varieties ; Symptoms ; Course. — Eczema is sometimes designated 
according to its location, as E. faciei, capitis, etc. Another designation, 
which has more scientific value, is according to the form and stage of 
the eruption, by which we have the following recognized varieties — to 
wit. Eczema papulosum, vesiculosum, pustulosum, rubrum, impetiginosum, 
and squamosum. A simpler and still more convenient classification is into 
eczema simplex, rubrum, impetiginosum, and squamosum. 

Eczema of the scalp is common in infancy, occurring as an eczema rubrum 
or impetiginosum. The eczematous exudation, mingling with the secretion 
of the sebaceous glands, which are numerous upon the scalp, forms a thick 
yellow crust. It is likely to extend beyond the hairy portion to the forehead 
and around the ears. This extension aids in establishing the diagnosis between 
eczema and certain other cutaneous eruptions of the scalp. Eczema of the 
external ear is sometimes primary, but in other instances it is consecutive to 
that of the scalp, and due to extension of the latter. Its common seat is in 
the angle behind the ear and upon the lobe of the ear, whence it often extends 
along the auditory meatus, narrowing its calibre, and impairing the hearing 
temporarily or even for years. Eczema upon the forehead commonly occurs 
in children from extension of the eruption from the scalp. The cheeks, lips, 
and chin are often also affected by eczema, which in this situation is com- 
monly eczema rubrum, and is attended by redness, swelling, and troublesome 
itching. The swollen and red appearance, with the crusts and marks produced 



DIAGNOSIS. 885' 

by scratching, often greatly disfigures the countenance. In children, when 
eczema occurs upon other parts, it is usually associated with that of the 
scalp, face, or ears, that in the latter situations being the most severe and 
obstinate. 

Eczema simplex is common in the summer months, being produced by the 
heat of the atmosphere, aided perhaps by other causes. The patient may 
appear well, or be somewhat indisposed, having febrile symptoms, and soon 
an erythematous patch of greater or less extent appears, upon which a cluster 
of the characteristic papules or vesicles soon occurs. These break, forming 
slight crusts, which are detached and the eczema declines, or it may continue 
longer, with successive crops of the eruption. 

In eczema ruhrum, since it is a more severe form of the disease, the fever 
and the local symptoms are greater than in the preceding variety, and the 
eczematous patch presents the appearance of a more intense inflammation. 
The papules or vesicles are often so minute as to be with difficulty recognized. 
They are soon broken, when they form with the secretion and exudation from 
the surface yellowish or brownish-yellow scabs. The discharge is more irri- 
tating, as it is more abundant, than in eczema simplex, and the adjacent skin 
is usually more inflamed from its contact. 

Eczema impetiyinodes is common in young debilitated children, in whom, 
in consequence of the cachexia, inflammations, of whatever character, are 
liable to be suppurative. This form of eczema presents at first the symptoms 
and features of eczema rubrum, but the transparent liquid of the vesicles 
soon becomes opaque, from the generation and admixture of pus-corpuscles. 
The crusts which form from the rupture and desiccation of the vesiculo- 
pustular eruptions are thick and greenish-yellow, and in infants the sebaceous 
glands, which are involved in the inflammation, pour out an abundant secre- 
tion, increasing the thickness of the crusts. This form of eczema is most 
common in infancy, and its usual seat is upon the scalp. 

Diagnosis. — Eczema presents in different instances so diff'erent an appear- 
ance that it is not always readily diagnosticated. It will aid in its diagnosis 
to recollect that it is in its nature a catarrh, afl"ecting primarily and chiefly 
the upper portion of the derma and the Malpighian layer, and although it 
may now present a dry or scaly appearance (E. squamosum), yet its history 
will show that there has been a discharge or moisture. In a large proportion 
of cases the physician is not able to detect papules or vesicles, since they are 
fragile and transient, breaking in the first thirty-six hours and not reappear- 
ing. Still, when they are absent we sometimes observe around the margin of 
the patch an appearance which indicates that they have been there. Their 
minuteness is occasionally such that they may escape notice on a cursory 
inspection when they are present and well defined. Acute eczema, aff"ecting 
a considerable extent of surface, is often attended by febrile symptoms, and 
may be mistaken for one of the eruptive fevers, but the absence of certain 
distinctive appearances which characterize these fevers, and the speedy 
appearance of the eruption and moisture, establish the diagnosis. Eczema 
can be readily diagnosticated from ordinary erythema, which is a superficial 
inflammation without moisture. The location of erythema intertrigo serves 
for its diagnosis, as it is evidently produced by the attrition of opposite sur- 
faces of the skin. Moreover, it lacks the elevated papillse, and the discharge 
does not stifi'en like that of eczema. Lichen, when acute, presents some 
resemblance to eczema, but it is dry and papular, the papules, though small, 
being detected by the finger as well as sight. The large and irregular phlyc- 
tenular, intense inflammation and oedema, and mode of extension of erysipelas ; 
large, scattered, and non-inflammatory vesicles of sudamina ; scattered and 
acuminate vesicles, without surrounding inflammation, of scabies, — are so 



886 ECZEMA. 

different from the eczematous eruption that the differential diagnosis from 
those diseases is readily made. Herpes circinatus can be distinguished from 
eczema by the circular shape, larger size, and greater permanence of the ves- 
icles, and the delicate, branny scales, which consist rather of epithelial cells 
than the product of exudation, as in eczema. 

Treatment. — In the treatment of this troublesome complaint local meas- 
ures are more inportant than internal medication, but the latter is often use- 
ful, and indeed necessary, in order to prevent relapses. In the infant eczema 
usually begins as an erythema, soon followed by papules and vesicles, and as 
the patient scratches the itching surface, pustules appear, and the eczematous 
surface presents a red and angry appearance, from which surface a thin and 
highly irritating watery secretion, mixed perhaps with serum, exudes. Thick- 
ening and infiltration of the skin occurs, and the itching is so severe that the 
patient cannot refrain from scratching or rubbing, unless under restraint. The 
itching and the consequent restlessness often deprive not only the child, but 
the mother or nurse, of the needed sleep. The cure of the disease is there- 
fore a matter of great importance, or, if not a complete cure, a mitigation of 
the suffering. The popular belief, which is also held by some physicians, 
that the cure of eczema or its sudden disappearance may endanger the safety 
of the child, causing even convulsions, is without foundation. Dangerous 
sequelae, if they occur, must be attributed to other causes and be regarded 
as coincidences. Hebra, the most distinguished dermatologist of the age in 
Avhich he lived, stated, after having treated twenty-five thousand cases of 
eczema, that he had never observed any ill-effects from its cure. 

In the treatment of eczema it is a matter of the greatest importance to 
prevent the infant — for infants are the chief sufferers — from scratching the 
inflamed surface. The method employed by Prof. White of Harvard Uni- 
versity has, I believe, been commonly approved and recommended by modern 
dermatologists. He applies a skull-cap of old cotton or linen, closely fitting, 
over the calvarium, and a mask of the same material covering the face, with 
apertures for the eyes, nose, and ears, gathered in under the chin and over- 
lapping two inches at the back of the head and neck. The cap and the 
mask protect the scalp and face when eczematous from the rubbing and 
scratching of the child. In a mild case this covering may perhaps be dis- 
pensed with, or be used only when the child is not watched ; but in severe 
cases it is best to wear it constantly. The object is to prevent entirely irri- 
tation of the inflamed surface by rubbing or scratching, which invariably 
aggravates the eczema. 

Dr. White also recommends restraint of the hands of the infant. For 
this purpose he takes a small pillow-case with a hole in the end sufficient to 
allow its head to pass through. The pillow-case is then drawn down over 
the body and limbs of the child, and its front and back surfaces are united 
by stitches or safety-pins between the body and arms on the two sides. This 
prevents the infant from lifting the hands to the face or scalp. The restraint 
from such treatment may seem cruel to the parents, but the child soon 
becomes accustomed to it, and suffers less in the end from not being able 
to scratch the inflamed surface, which always aggravates the disease. 
Whatever ointment is used can be conveniently applied under the cap or 
mask. 

Before considering the details of treatment it is well to bear in mind the 
following facts, which will aid in the selection of remedies : Acute eczema 
requires soothing remedies, and should not, as a rule, be treated with soap 
and water. Crusts forming over vesicles should not be removed, unless 
accompanied by itching or purulent or decomposing secretions underneath. 
If so, they should be removed at once by soothing lotions or cataplasms. If 



TREATMENT. 887 

vesicles form rapidly and are accompanied by severe itching, they may be 
broken, so that the secretion is released, which may diminish the pruritus. 
In using mercurial and lead preparations care should be taken not to apply 
them over an extensive area, since they are absorbed and might produce sys- 
temic effects of a toxic nature. 

Removal of Crusts. — The crusts which in many cases form upon eczema- 
tous surfaces, and under which irritating secretions are confined, increase the 
itching and restlessness of the child and interfere with the action of local 
remedies. Oleaginous substances should be used for their removal, as sweet 
oil or cold cream, and they should be applied in such quantity that they soak 
thoroughly into the crusts. On smooth surfaces, as the face, a mild ointment 
like simple cerate, thickly spread on surgeon's lint, may be applied over the 
crusts, which will to a great extent be detached and removed with the plaster. 
Salicylic acid has also come into use as a solvent of crusts. The following 
ointment, rubbed in hourly or applied thickly spread on surgeon's lint, renders 
the surface clean in a few days : 

R. Acidi salicylici, ^j ; 

Vaseline, ^iss. Misce. 

The first indication has now been accomplished, that of denuding the sur- 
face of crusts. The next indication is to cure the disease. 

In commencing the treatment of acute eczema the lotio nigra of the 
Pharmacopoeia, consisting of calomel and lime-water, may sometimes be 
advantageously employed, applied by a large camel's-hair pencil or soft 
cloth, and followed perhaps by diluted oxide-of-zinc ointment or vaseline. 
The black wash should be well shaken before being used. 

Hebra's diachylon ointment is also soothing and useful for acute eczema, 
if properly made ; but, unfortunately, much of that in the shops is incor- 
rectly prepared and is unsuitable. The following is the correct formula : 

R. Olei olivse opt., f^v; 
Pulv. lithargyri, .^i-^ij ; 
Aquae, q. s. Misce. 

The oil is mixed with a third of a pint of water, and heated in a steam-bath 
to boiling. The litharge, finely powdered, is then sifted in with constant 
stirring. The boiling is continued until the fine particles of litharge dis- 
appear. During the boiling a little water is added from time to time to keep 
up the original amount, and water remains in the vessel when it is removed 
from the fire. The mixture is then constantly stirred until cool. The oint- 
ment should be made of the best oil and litharge, and when properly made it 
resembles butter in consistence, and to. a certain extent in color, having a 
light-yellow hue. It should be freshly made when needed, and renewed 
every week. 

Another good ointment for acute eczema is the following, prepared orig- 
inally by McCall Anderson : 



:. Pulv. bismuth i oxidi. 


7>} ; 




Acidi oleici, 


.^.i; 




Cerse albae, 


5iij ; 




Vaselini, 


31X ; 




01 ei rosse, 


^ii.j- 


Misce. 



This also resembles butter in appearance, and may be applied several times 
daily. 

A considerable number of other soothing ointments have been used and 



888 ECZEMA. 

recommended by dermatologists for acute eczema. One drachm of carbonate 
of zinc or subnitrate of bismuth to one ounce of rose-water ointment may 
be employed, but it possesses no advantage over the ointments mentioned 
above, except that it is easier of preparation and more uniform ; and the 
same may be said of the ointment of the oxide of zinc, which has been more 
used in acute eczema than any other ointment. Hebra's or Anderson's oint- 
ment, if carefully prepared according to the formula given above, is probably 
not surpassed by any other ointment for its soothing or curative action. 

Ointments have, I think, given more satisfaction than dusting powders in 
acute eczema, but in the commencement of eczema papulosum or vesiculo- 
sum, common powdered starch, talc (magnesium silicate), semen lycopodii, 
or rice-starch (amylum oryzae), dusted upon the inflamed surface does afford 
some relief. 

The following formula is essentially that recommended by Kaposi, the 
glycerin being omitted : 

R. Amyli oryzse, giij ; 

Talc, venet., 
Flor. zinci, 
Pulv. iridis Florenti, da. 5JX- Misce. 

Camphor may be added to relieve itching in the proportion of 2 per cent. 

Van Harlingen states that in eczema intertrigo and in other forms of 
eczema attended by much burning and itching, but without discharge, the fol- 
lowing prescription gives great relief: 

R. Pulv. cam phorse, 3j ; 

Pulv. amyli, 
Pulv. zinci oxidi, da. ,^ss. Misce. 

To be dusted upon the surface or upon the soft side of surgeon's lint, and 
the lint to be applied upon the inflamed part. It should not be used upon a 
raw surface. Carbonate of zinc and subnitrate of bismuth are also useful 
dusting-powders for such cases. 

Itching is the symptom which produces the chief suffering and restless- 
ness of the patient : 2 per cent, of camphor added to ointments or washes 
gives some relief to this symptom. A mixture of 2 per cent, of acetic acid 
in water, or J to a 2 per cent, solution of aluminium acetate in water, it is 
said also relieves the pruritus. Carbolic acid, properly diluted, is one of the 
most effectual agents to relieve the itching. But, as we have stated above, 
applications containing water frequently applied are likely to aggravate acute 
eczema. If the above remedies fail to give relief, and the pruritus makes the 
child restless, the following formula may be tried : 

U. Acidi carbolioi, gr. xv ; 

Spts. vini Gallici, ^iv-^vij ; 

Spts. lavendul., 

Eau de cologne, ad. ^vj^. Misce. 

This can be applied by a camel's-hair pencil. The addition to it of cocaine 
might render it more effectual in relieving the itching. The following lotion 
has also been considerably used in New York, and has been recommended by 
dermatologists : 

R. Acidi hydrocyan. dil,, ^ij ; 

Bismuthi subnitrat., .^ij ; 

Aquse destillat., ^viij. Misce. 
Ft. lot. 



TREATMENT. 

By the above treatment the inflammation usually abates, but the ecze- 
matous patch may be still hyperaemic, infiltrated, and desquamating, and 
additional measures are required to restore it to the normal state. Moder- 
ately stimulating applications are now needed, and tar is the best agent for 
this purpose. Tar should never be applied in moist eczema. Its use should 
be reserved for dry and desquamating eczema. The various tars which have 
been used with success in eczema are the pix liquida or pine tar, the oleum 
fugi or beech tar, the oleum rusci or birch tar, and the oleum cadinum, 
obtained from the Jiunperis oxycedrus. Tar penetrates all the layers of the 
skin, for when used externally it has been found in the urine. In a few 
patients it has been stated that its employment has been followed by rigors, 
fever, headache, and vomiting. If such symptoms arise, it should of course 
be discontinued. The following formulae may be employed : 

R. Ung. picis liquidse, ,^j ; 

Alcoholis, ^ij. Misce. 

R. Olei rusci vel cadini, f^j ; 

Alcoholis, f^ii-iij. Misce. 

R. Olei rusci vel cadini, f^j ; 

Alcoholis, 
^theris, da. f^iss. Misce. 

The alcoholic solutions of tar should be applied by a small bristle brush 
(Heitzman). 

R. Picis liquidse, ,^j ; 

Adipis, Jj. Misce. 

R. Picis liquidse, .^j ; 

Ung. zinci oxidi, ^j. Misce. (Van Harlingen.) 

Van Harlingen states that sulphur may be used with the tar, often with 
the best results. He employs the following formula : 

R. Sulphur, prpecipitat., 

Picis liquidae, del. ,^ss ; 

Ung. zinci oxidi, ^j. Misce. 

He adds that, like other tarry preparations, it should be used in small quan- 
tity and rubbed thoroughly into the skin. 

In chronic eczema, in which the inflammation is mild and the surface 
scaly and dry, more stimulating applications are required than those recom- 
mended above. For such cases the following prescriptions will be found 
useful : 

R. Unguenti hydrarg. ammoniat., ^ij ; 

Unguenti zinci oxidi, 

Unguenti aqute rosse, dd. ^. 

Or, 

R. Pulv. hydrarg. chlor-mitis, gr. v; 

Ung. zinci oxidi, 3J. Misce. 

Apply three or four times daily to the inflamed surface. 

Constitutional Treatment. — No one line of treatment is suitable for every 
patient. Among the city poor strumous cases are common, and cases also in 
which, without any pronounced diathetic state, the cause is apparently a 
reduced state of the system from innutritions diet and other antihygienic 
conditions. Such cases require better diet and a mode of life more in accord- 
ance with sanitary requirements. On the other hand, I have observed cases 
of eczema which seemed to be produced or rendered more intractable by a 
plethoric state of the system, especially in the nursing infant, when the milk 
of the mother or wet-nurse was unusually rich or abundant. While, there- 
fore, ill-nourished and weakly children require better regimen, with perhaps 



890 



SCABIES. 



vegetable and ferruginous tonics, the plethoric require reducing treatment, 
though of a gentle kind. Their food should be plain and unstimulating. 
Indigestible articles, as pastries, cheese, and rich sauces, should be avoided, 
especially when symptoms of indigestion are present. Indigestion or other 
aberration of the system from the healthy standard should be promptly cor- 
rected. Saline aperients are useful in case of constipation and of a plethoric 
habit. The saline diuretics, as the acetate and citrate of potassium, are often 
beneficial in acutQ eczema with febrile symptoms, especially if the urine be 
rather scanty. The following formula is recommended by Dr. A. R. Robinson : 

R. Potassii acetatis, ^iss; 

Spts. setlieris nitrosi, .^ij ; 

Syrupi aurantii, ,^v) ; 

Aquae carui, q. s. ad Jiij. 

One teaspoonful three times daily to a child of one year. 

In acute as well as chronic eczema any departure from the healthy stand- 
ard, whether in the digestive organs, the kidneys, or other part of the system, 
should be corrected so far as possible, since eczema is more readily cured 
when the functions of the internal organs are normally performed. 



Scabies. 

The diseases of the skin previously considered are non-contagious. 
Scabies, on the other hand, is one of the most contagious diseases by con- 
tact. It is produced by an animal parasite, known as the itch-mite, or Acams 
scahiei. The inflammation is caused by the female only, which burrows, 
making for itself a canal or cuniculus, in which its eggs are deposited. The 
male does not burrow, but conceals itself under the scales or crusts which 
result from the inflammation produced by its partner, or it burrows only 
sufiiciently to produce a covering and shelter. From observations made by 
Eichstedt, Gudden, and others the female has been found within half an hour 
after being placed upon the skin to have concealed herself in the epidermis, 



Fig. 48. 



Fig. 49. 



Fig. 50. 








Fig. 51. 









Fig. 48. The itch animalcule, Acarus scahiei, vieAved upon the back, showing its figure and 
the arrangement of its spines and filaments. The female, which is somewhat larger than the 
male, has a length of one-eightieth to one-sixtieth of an inch. 

Fig. 49. The foot and last joints of the leg of the itch animalcule. 

Fig. 50. The male itch animalcule, viewed upon the under surface, showing its legs and 
lohulated feet. 

Fig. 51. Ova of the itch animalcule. 



and the burrow which she constructs is arched and tortuous and four or five 
lines in length, shorter or longer. The acarus has the shape of a tortoise. 
It can, when fully grown, be detected by the eye as a minute whitish point. 



DIA G^^OSIS—TEEA TMENT. 891 

The young acarus has six, the mature eight, articulated legs, with suckers 
upon the two anterior pairs and hairs on the posterior. The head, which can 
be elongated or retracted, is provided with two jaws. The upper surface 
is covered with spines directed backward so as to prevent retrogression in the 
burrow. She leaves behind her in the cuniculus, as she advances, her moulted 
skin, excreta, and eggs, which hatch on the eleventh day. The mother-acarus 
is always found at the remote end of the burrow, where it can be seen by the 
unassisted eye as a minute whitish or sometimes brownish speck, and from 
which it can be lifted by the point of a needle, to which it clings. The 
cuniculi can also be ^een by the naked eye, looking, says Niemeyer, like the 
" scars of needle-scratches," and containing the young acari in various stages 
of growth. 

The acarus by its burrowing produces an irritation and troublesome itch- 
ing, which is the chief cause of the suffering of the patient. At the point 
where the acarus penetrates the cuticle the inflammation gives rise to a single, 
small, and acuminate vesicular or papular eruption, the cuniculus extending 
away from it. We often find ecthymatous pustules and abrasions intermin- 
gled with the vesicles, the result of frequent scratching. The itching is most 
Intense and the acarus most active at night, when the patient is warm in bed. 
Scabies most frequently appears, especially in adults, first upon the hands, 
between the fingers, where the skin is thin, and it extends thence along the fore- 
arm and over the thighs and abdomen. In children it not infrequently occurs 
upon the buttocks, thighs, feet, etc., while the hands and forearms escape. 

Diagnosis. — Correct diagnosis is important, because the treatment 
required is different from that in any other exanthem, and because the sus- 
picion of having this disease always renders one solicitous to know the exact 
nature of the eruption. Scabies can be diagnosticated from those diseases 
for which it may be mistaken by the following characters : its occurrence 
where the cuticle is thin and delicate, as between the fingers, along the ante- 
rior aspect of the forearm, upon the abdomen, thighs, and inside of the feet; 
small size, acuminate shape, and isolated position of vesicles ; the intermin- 
gling with the vesicles of other forms of eruption, as papules and pustules, 
and the presence of linear scars and abrasions produced by the scratching; 
itching most intense at night ; absence of fever ; absence of the disease from 
posterior aspect of body and arms and from head and face. Scabies may be 
distinguished by the vesicular character of the eruption from all other exan- 
thematic affections except eczema, sudamina, and herpes. Eczema is most 
tjommon on the scalp and face, where scabies does not occur, and unlike 
scabies its vesicles are round and thickly aggregated in clusters ; in eczema 
there is a smarting or prickling sensation very different from the intense itch- 
ing of scabies. In herpes the vesicles are large, rounded, and in clusters, 
and attended by a burning or pricking sensation, with but little itching. The 
eruption in sudamina is vesicular and discrete, as in scabies, but it is globular 
and accompanied by no itching or other local symptoms. 

Treatment. — As scabies is due to a species of acarus which burrows in 
the epidermis, it can only be treated successfully by measures which destroy 
this animalcule. If it be destroyed, the disease gets well of itself. Sulphur 
has been employed for a long period for this purpose, since sulphurous acid, 
which is evolved from the sulphur, is destructive to the animalcule. The 
unguentum sulphuris, if thoroughly applied, will rarely fail to eradicate sca- 
bies. The internal use of sulphur aids the external treatment, since a portion 
of the gas which is generated escapes through the pores of the skin. The 
chief objection to the employment of sulphur is its exceedingly unpleasant 
odor, which is noticeable, however disguised by perfume. Sulphur or any 
other substance employed externally has more effect if it be preceded by a 



892 SCABIES. 

bath, which softens the epidermis, and therefore favors the entrance of the 
remedy into the pores of the skin and the cuniciili. 

Hehiierich's ointment is very effectual in the treatment of scabies. It 
consists of two parts of sulphur, one of carbonate of potassium, and eight 
of lard. " M. Hardy afterward perfected the method, so as radically to cure 
the disease in two hours. He proceeded in the following manner : The patient 
first undergoes a friction of his whole body for half an hour with soft soap, 
in order to cleanse the skin and break up the burrows ; a warm bath of an 
hour's duration follows, during which the skin is thoroughly rubbed, in order 
to complete the destruction of the burrows ; after which frictions for half an 
hour and upon the whole surface are practised with Helmerich's ointment. 
This completes the cure. Out of 400 patients subjected to this treatment 
only 4 returned to the hospital."^ 

M. Albin Gras experimented with different substances in order to ascer- 
tain their relative destructiveness to the acarus. The following table gives- 
some of the results of his experiments : 

Immersed in pure water, the acarus was alive after three hours. 

" saline water, the acarus moved freely after three hours. 

" Goulard's solution, the acarus lived after one hour. 

" olive, almond, or castor oil, the acarus lived more than two hours. 

" lime-water, the acarus died in three-fourths of an hour. 

" vinegar, " " twenty minutes. 

alcohol 
" turpentine, " " nine " 

" iodide of potassium, the acarus died in four to six minutes. 

It is seen that vinegar, lime-water, alcohol, turpentine, and iodide of 
potassium destroy the acarus in a short time. They may be employed in 
the same manner as the sulphur ointment. Camphor is also destructive ta 
this animalcule, and the linimentum camphorge, thoroughly applied, is a good 
remedy for uncomplicated scabies. 

In order to avoid the odor of sulphur, which is so offensive, one of the 
following ointments may be employed if the patient be fastidious : 



. Unguent, hydrarg. ammoniat., 


Ey, 


Moschi, 


gi-. ij ; 


01. lavendul., 


gtt. ij ; 


01. amygdal., 


3j. Misce.* 



If scabies be extensive this should not be used, as its application over 
considerable area might endanger salivation, but the following, which is rec- 
ommended by Bazin, and is said to cure the disease with three applications,, 
may be used instead : 

R. Anthemis pulv., 
Adipis, 
01. olivje, da. 5J. Misce. 

In cases which have been protracted, and in which ecthymatous and other 
secondary eruptions have occurred, the scabies can ordinarily be readily cured^ 
while the other eruptions remain and disappear more slowly. A knowledge 
of this is important, since the sulphur or other ointment employed for the 
cure of scabies should be discontinued when the itching ceases and vesicles 
no longer appear, and tonic or other treatment appropriate to cure these 
secondary eruptions should be employed instead. The sulphur ointment 
continued after the scabies is cured does harm, since it irritates the cuticle. It 
is essential in the treatment of scabies that the linen be frequently changed. 

^ Stille's Therapeutics, etc., vol. ii. p. 561. ^ From Wilson. 



INDEX. 



ACEPHaLUS, 97 
A crania, 97 
Albuminuria in diphtheria, 392 
Albuminuria in scarlet fever, 300 
Animal heat, 92 
Aphthous stomatitis, 742 
Appendicitis, 856 

etiology, 857 

anatomical characters, 858 

symptoms, 859 

diagnosis, 861 

prognosis, 862 

treatment, 863 
Artificial feeding, 72 
Atelectasis, 687 

acquired, 687 

symptoms, anatomical characters, 689 

treatment, 690 
Attitude in disease, 87 

BATHING in infancy, 80 
Blue disease, 106 
Booker, W. D., investigations relating to 

intestinal bacteria, 781 
Brain, incomplete, 98 

in infancy and childhood, 520, 521 
Brain, atrophy of, 522 
hypertrophy of, 523 

pathological anatomy, 523, 524 
causes, 524 

symptoms, case, 525, 526 
diagnosis, 526 
prognosis, treatment, 527 
Thrombosis, 527 

anatomical characters, 528 
causes, 529 

symptoms, diagnosis, prognosis, 530 
treatment, 531 
Congestion of, 531 
causes, 531, 532 

symptoms, anatomical characters, prog- 
nosis, 533 
treatment, 534 
Hemorrhage of, 534 
Dropsy of, congenital, 542 
acquired, 548 
Bronchial phthisis, 234 
Bronchitis, 677 

causes, anatomical characters, 677-679 

symptoms, 680 

diagnosis, 682 

prognosis, treatment, 683-687 

CALCULI, 874 
Cancram oris, 744 
Caput succedaneum, 117 



Caries, vertebral, 637 

causes, symptoms, diagnosis, 637-639 
prognosis, treatment, 640 
Catarrhal laryngitis, 644 
Catarrhal pharyngitis, 756 
Catarrh, intestinal, of infancy, 785 
Cephalpematoma, 117 
Cerebro-spinal fever, 470 
definition, 470 
history, 470-472 
etiology, 472 
its contagiousness, 474 
secondary, 476 
sex, age, 477 
symptoms, 478 
mode of commencement, 479 
nervous system, 480 
digestive system, 485 
pulse, temperature, 486 
respiratory system, 487 
cutaneous surface, 488 
urinary organs, 488 
special senses, 489 
svmptoms of endemic or naturalized, 

490 
nature, 491 

anatomical characters, 492 
prognosis, 495 
diagnosis, 497 
treatment, 498 
curative, 498 
internal, 501 
Cerebro-spinal system, diseases of, 520 
Chicken-pox, 353 
Childhood, 35 

changes of organs, 35 
Cholera infantum, 799 

anatomical characters, 800 
nature, 802 

diagnosis, prognosis, treatment, 803- 
808 
Chorea. 608 
causes, 609 
sex, 609 
uterine irritation, 610 
anpemia, 610 
rheumatism, 610 

lesions of brain and spinal cord, 615 
fright, 614 
imitation, 614 
intestinal irritation, 614 
anatomical characters, 615 
symptoms, 616 
prognosis, course, 618 
diagnosis, 619 
treatment, 619 

893 



894 



INDEX. 



Circulatory system in infancy, 90 
Clothing in infancy, 81 
Colitis, 808 
causes, 808 
symptoms, 809 
diagnosis, 809 
prognosis, 809 
treatment, 810 
Colostrum, 48 

constituents of, 48, 49 
Congestion of brain, 531 
of spinal cord, 635 
of stomach, 771 
Conjunctivitis, 120 
mild or catarrhal, 120 
purulent ophthalmia neonatorum, 121 
symptoms, 122 
course, results, 123 
preventive measures, 123, 124 
treatment, 125 
Constipation of new-burn, 155 
causes, 156 
symptoms, 157 
treatment, 158 
Constipation, symptomatic, 811 
idiopathic, 813 
causes, 813-815 
symptoms, 815 
treatment, 817 
hygienic, 818 
therapeutic, 820 
Consumption, 221 
Convulsions, clonic, 570 
internal, 590 
causes, 591 

anatomical characters, symptoms, 592 
case, 593 
diagnosis, prognosis, mode of death, 

594 
treatment, 595 
Coryza, 641 

anatomical characters, 641 
symptoms, prognosis, treatment, 642 
Cough, nervous, 737 
causes, 737 
treatment, 737, 738 
Cranial sinuses, thrombosis in, 527 
Craniotabes, 190 
Croup, false or spasmodic. (See Spasmodic 

Laryngitis, 646. ) 
Croup, membranous (diphtheritic), 650 
etiology, 650-653 
anatomical characters, 654 
symptoms, 655 
diagnosis, 656 
prognosis, 659 
treatment, preventive, 660 
internal, 663 
surgical, 666 
intubation in, 667-676 
tracheotomy in, 675 
Cryptorcliia, 874 
Cyanosis, 106 

its literature, 106 

sex, time of commencement, 107, 108 

symptoms, 108-110 



Cyanosis: prognosis, mode of death. 111. 
112 
nature of malformations, 112 
mode of compensation, 113 
morbid anatomy, 113, 114 ' 

theories relating to, etiology of, 114, 115 
treatment, 116 

DACTYLITIS, strumous, 208 
syphilitica, 259 
Dentition, 750 

pathological results, 751 
diagnosis, treatment, 753 
Dentition, second, 755 
Diagnosis of infantile diseases, 85 

features, appearance of head, trunk,, 

and limbs in disease, 85-87 
attitude, movements, voice, 87 
respiratory system, 87-90 
circulatory system, 90 
animal heat, 92 
digestive system, 93 
nervous system, 94 
Diarrhoea of the new-born, 153 

treatment, 154 
Diarrhoea, simple, 781 

causes, sym])toms, 782 
anatomical characters, 783 
prognosis, treatment, 784 
Diarrhoea, inflammatory, 785 
etiology, 787 
age, 791 
dentition, 791 
anatomical characters, 795 
Diarrhoea, choleriform, 799 

treatment, 803 
Digestive apparatus, diseases of, 739 
Digestive system in infancy, 93 
Dilation of stomach, 775 
Diphtheria in scarlet fever, 293, 294 
Diphtheria, 356 
history, 356 
etiology, 360 

mode of propagation, 364 
contraction from animals, 366 
age, 368 
incubation, 370 
nature, 371 
diagnosis, 376 
pultaceous pharyngitis, 377 
scarlatinous pharyngitis, 378 
gangienous pharyngitis, 378 
herpetic pharyngitis, 378 
ulcero-membranous pharyngitis, 378 
anatomical characters, 378 
the blood, 381 
brain and spinal cord, 382 
tonsils, 382 
faucial surface, uvula, epiglottis, lungs, 

383 
vesicular emphysema, 384 
pulmonary apoplexy, 384 
lymphatic glands, 3*84 
heart, mouth, stomach, intestines, 385 
spleen, liver, kidneys, 385, 386 
symptoms, 386 



INDEX. 



895 



Diphtheria: temperature, 388 

nares, 389 

eye, ear, mouth, 389, 390 

oesophagus, stomach, intestines, 390 

genito-urinarv organs, 391 

skin, 392 

albuminuria, 392 

paralysis, 395 

clinical history, 396 

time of commencement, 397 

loss of tendon reflexes, 398 

palatal paralysis. 399 

multiple paralysis, 400 

cardiac paralysis, 401 

etiology, 406 

prognosis, 411 

preventive treatment, 413 

treatment, 416 

hygienic, 417 

stimulants, 418 

quinine, tinctnra ferri chloridi, potas- 
sium chlorate, 421 

hydrargyri chloridum corrosivum, 423 

calomel, 425 

turpentine, 426 

pilocarpine, sodium benzoate, 427 

treatment, local, solvents, 428 

albuminuria, 429 

paralysis, 429 
Dyspepsia, 765 
Dysuria, 874 

ECLAMPSIA, 570 
causes, 571 

premonitory stage, symptoms, 572 

partial eclampsia, 573 

anatomical characters, 574 

diagnosis, prognosis, 574, 575 

treatment, 576 
Eczema, 883 

anatomy, 883 

etiology, varieties, symptoms, 884 

diagnosis, 885 

treatment, 886 
Empyema, 712, 729 
Encephalocele, 100 
Endocarditis in rheumatism, 506 
Enteritis, 808 

causes, 808 

symptoms, diagnosis, 809 

prognosis, treatment, 809, 810 
Entero-colitis, 785 
Enuresis, 866 

etiology, 868 

prognosis, treatment, 870 
Epilepsy, 578 

etiology, predisposing causes, 578 

age, exciting causes. 578, 579 

symptoms, minor and major attacks, 580 

aura, 580-582 

anatomical characters, 583 

pathology, 584 

diagnosis, 585 

prognosis, treatment, 586-589 
Erysipelas, 512 

point of commencement, causes, 514 



Erysipelas : premonitory symptoms, 515 

symptoms, 516 

prognosis, duration, 517 

modes of death, pathological anatomy,, 
517, 518 

treatment, 518 
Erythema, 877 

prognosis, diagnosis, treatment, 878 
Exercise in infancy, 83 

FEEDING, infantile, 64 
over-feeding, 64 
insufficient, 65 
improper, ^Q, 67 
quantity of food required, 68 
statistics, 69 
Feeding, artificial, 72 
Fever, intermittent, 449 
Fever and ague, 449 
Foetus, effects of maternal impressions on,. 

36 
Follicular gastritis, 777 
Fright a cause of chorea, 619 

pALACTAGOGUES, 56 
\J Gangrene of mouth, 744 

anatomical characters, 744 

causes, symptoms, 745 

diagnosis, 746 

prognosis, 747 

treatment, 748 
Gastritis, 771 

cause, 777 

age, 772 

symptoms, anatomical characters, 773 

diagnosis, prognosis, treatment, 774 

follicular (diphtheritic), 775 
G astro-intestinal bacteria, 779 
Gastro-intestinal hemorrhage, 150 
Gastro-malacia, 776 

case, 777 
German measles, 328 
Glands in scrofula, 207 
Glottis, spasm of, 590 
Green color of the stools, 780 
Growth of infants, 43 

H.EMATEMESIS and melsena neona- 
torum, 150 
age, 150 
etiology, 151 

diagnosis, prognosis, treatment, 153 
Heart-malformations, 104 
Hemorrhage, intracranial (meningeal, cer- 
ebral), 534 
causes, anatomical characters, 535 
meningeal, 536 
cerebral, 537 
symptoms, 538 
capillary, 539 

symptoms in meningeal, 540 
diagnosis, prognosis, treatment, 541 
Hemorrhage, umbilical, 128 
Hemorrhage, gastro-intestinal, 150 
Hooping-cough, 431 
Hydrencephalocele, 100 



896 



INDEX. 



Hydrocephalus, congenital, 542 

anatomical characters, 542 

etiology, symptoms, 545 

prognosis, treatment, 547 
Hydrocephalus, acquired, 548 

causes, 548 

anatomical characters, symptoms, 549 

prognosis, treatment, 550 
Hydrocephalus, spurious, 566 

anatomical characters, case, 566 

symptoms, 567 

causes, 568, 569 

diagnosis, prognosis, 569 

treatment, 570 

ICTEKUS neonatorum, 132 
theories of its causation, 133-135 
prognosis, treatment, 135 
Indigestion, 765 
causes, 765 
symptoms, 766 
prognosis, 767 
diagnosis, treatment, 768 
Infancy, 33 
organs in, 34 
mental faculties in, 34 
Infantile paralysis, 624 
Infarctions, uric-acid, 866 
Inflammation of sterno-cleido-mastoid mus- 
cles, 118 
Intermittent fever, 449 
etiology, 450 
symptoms, 451 
treatment, 453 
Internal couvulsions, 590 
Intestinal catarrh of infancy, 785 
etiology, 787 
age, dentition, 791 
symptoms, 792 
anatomical characters, 797 
diagnosis, 798 
prognosis, 799 
Infantile cholera, or choleriform diar- 
rhoea, 799 
nature, 802 

diagnosis, prognosis, 803 
treatment, 803-808 
Intestinal worms, 822 
Intracranial hemorrhage, 534 
Intubation, 668 

difficulties of operation, 671 
accidents and dangers of, 672 

asphyxia, 673 
mode of extraction, 674 
after-management, 674 
Intussusception, 837 

without symptoms, 837 
with symptoms, 838 
previous health, causes, 838 
age, seat, pathological anatomy, 839 
in small intestines, 839 
_ • cases, 840-842 
in large intestines, 842 
symptoms, 844 
diagnosis, 846 
duration, prognosis, 846, 847 



Intussusception in large intestines: mode 
of death, 848 
treatment, 849 

JAUNDICE of new-born, 132 
Joints, inflammation of, in rheuma- 
tism, 505 

KEKATITIS, strumous, 217 
herpetic or phlyctenular, 217 
parenchymatous or diffiise, 220 
Kidneys in diphtheria, 392 
in rachitis, 201 
in scarlet fever, 300 

LACTATION, mode of determining capa- 
bility, 44 
hindrances to, 44 
tender nipples, 44 
ill-health, 44, 45 
syphilis, 46 
inflammations, 46 
erysipelas in mother, 47 
colostrum, 48 
Lactic acid a cause of rachitis, 183, 184 
Laryngismus stridulus, 590 
Laryngitis, catarrhal, 644 
symptoms, 644 
chronic, 644 

anatomical characters, treatment, 645 
spasmodic, 646 

causes, symptoms, 646 
anatomical characters, pathology, 647 
diagnosis, treatment, 647, 648 
Lockjaw, 159 

Lung, inflammation of. (See Pneumonia.) 
in tuberculosis. (See Tuberculosis.) 
in diphtheria. (See Diphtheria.) 

MALFORMATIONS, 97 
acrania, 97 
incomplete brain, 98 
meningocele, encephalocele, hydren- 

cephalocele, 99, 100 
spina bifida, 101 
congenital abnormalties in circulating 

system, 104 
malformations of heart, 104 
cyanosis, 106 
Mammary glands, 119 
Mastitis, 119 
Measles, 263 

etiology, symptoms, 263 
complications, 266 
anatomical characters, nature, 268 
diagnosis, prognosis, treatment, 269 
German, 328 
Meconium, 33 
Membranous croup, 650 
Meningeal hemorrhage, 534 
Meningitis (tubercular and non-tubercular), 
551 
age, 552 ^ 

pathological anatomy, 553 
causes, 556 
premonitory stage, 557 



INDEX. 



897 



Meningitis : symptoms, 558 
case, 561 

diagnosis, prognosis, 562 
treatment, 563 
Meningocele, 100 
Milk, human, 49 
composition, 50 
modification from diet, 50 
from insufficient food, 50 
from retention in breast, 51 
by age and mental impressions, 51 
by catamenial function and by preg- 
nancy, 52 
difference in quantity and quality, 54 
efiect of medicines, 54 
rules in regard to nursing, 55 
scantiness: cause, treatment, 55 
Morbilli. (See Measles.) 
Morbus cseruleus. (See Cyanosis.) 
Mortality of early life, causes, 39 
internal malformations, 40 
feebleness of system, 40 
hereditary disease, 40 
infectious disease, 40 
anti-hygienic conditions, 41 
improper food, 42 
Mother, care of, in pregnancy, 35 
Mouth, inflammation of, 739 

gangrene of, 744 
Muguet, 145 
Mumps, 445 

etiology, incubation, 445 
symptoms, anatomical characters, 446 
complications, sequelae, 446, 447 
diagnosis, prognosis, treatment, 447, 448 
Myelitis, 624 

NECROSIS, 744 
Nephritis in diphtheria, 392 
Nephritis in scarlet fever, 300 
Nervous cough, .737 
Nervous system in infancy, 94 
Newly-born, diseases of, 97 
Noma, 744 
Nurse, selection of, 59 

OBSTETRICAL scarlatina, 279 
Oedema neonatorum, 176 
Qi^sophagitis, 763 

anatomical characters, treatment, 764 
Oidium albicans, {^ee Thrush.) 
Ophthalmia, strumous, 217 

herpetic or phlyctenular keratitis, 217 

duration, diagnosis, prognosis, 218 

treatment, 218, 219 

parenchymatous or diffuse keratitis, 220 
Otitis in scarlet fever, 296 

PAPULAR diseases, 882 
Paralysis, 621 
causes : a change in the blood, 621 
reflex influence, 621 
injury of a nerve, 621 
anatomical change in muscular fibres, 

621 
disease of nervous centres, a case, 622 
.67 



Paralysis : Poliomyelitis acuta anterior, 624 
symptoms, 624 

diagnosis, prognosis, etiology, 625-627 
treatment, 628 
Paralysis, facial, 630 

causes, symptoms, 630 
Paralysis, pseudo-hypertrophic, 631 
symptoms, 631, 632 
anatomical characters, causes, 633 
prognosis, treatment. 634 
Parotiditis, 445 
Pemphigus neonatorum, 177 
simplex, 177 
cachecticus, 178 
anatomy, treatment, 178 
Peptonized milk, 75 
Peripharyngeal abscess, 759 
age, causes, 759 

anatomical characters, symptoms, 760 
diagnosis, 762 
prognosis, treatment, 763 
Perityphlitis, 856 
etiology, 857 

anatomical characters, 858 
symptoms, 859 
diagnosis, 861 
prognosis, 862 
treatment, 863 
Pertussis, 431 

incubative period, age, causes, 432 
pathological anatomy, 433 
symptoms, first period, 434 
second period, 434 
third period, 435 
complications, 436 
diagnosis, prognosis, 439 
treatment, 440 

carbolic acid, cocaine, antipyrine, 441 
quinine, 442 
sulphur, 443 
prophylaxis, 445 
Pharyngitis, catarrhal, 756 

anatomical characters, 756 
symptoms, prognosis, diagnosis, 757 
treatment, 758 
Phlebitis, 527 
Phthisis, 221 
Pleurisy (pleuritis), 704 
frequency, 704, 705 
causes, 705-707 
anatomical characters, 710 
plastic, 711 

sero-fibrinous, 711, 712 
purulent, 712 
hemorrhagic, 713 
symptoms, 716 
physical signs, 718 
palpitation, 719 
percussion, 719, 720 
auscultation, 720 
diagnosis, 721 
prognosis, 723 
treatment, 725 
internal, 726 
thoracentesis, 728 
empyema, 729 



898 



INDEX. 



Pleurisy : treatment : mode of operating, 730 
admission of air, 733 
injury to lung by instruments, 734 
washing pleural cavity, 734 
extraction of portion of ribs, 736 
Pneumonia, 690 

catarrhal, etiology, 690-693 
croupous, etiology, anatomical charac- 
ters, 693-696 
septic or embolismal, 696 
cheesy, 696 

symptoms of croupous, 398 
physical signs, 699 
diagnosis, 700 
prognosis, treatment, 701 
Post-mortem gastric softening, 776 
Pott's disease, 637 
Pregnancy, care of mother in, 35 
Pseudo-membranous croup, 650 
Pulse in health, 90 
in disease, 91 
influenced by excitement, 91 

RACHITIS, 179 
frequency, 179, 180 
age, 181 
causes, 182 

anatomical characters, 186 
cartilaginous changes, 186 
osseous changes, 186 
pathology of, 188 

anatomical characters in stage of de- 
formity, 188 
changes in cranial bones, 189 
craniotabes, 190 
symptoms, 190, 191 
changes in vertebrse, 192 
in maxilla?, 193 
in ribs, 194 

in bones of upper extremity, 196 
in bones of lower extremity, 196 
effect on dentition, 198 
changes in soft tissues, 198 
reconstruction, 199 
symptoms of rachitis, 200 
complications and secjuelee, 201 
diagnosis, prognosis, 201-203 
treatment, 203 
Eemittent fever, 454 

symptoms, diagnosis, prognosis, 455 
treatment, 455, 456 
Kespiratory system, diseases of, 641 

in infancy, 87 
Retropharyngeal abscess, 759 
Rheumatism, acute, 503 
causes, 504 
symptoms, 505 

duration, prognosis,, diagnosis, 509 
treatment, 510 
Rheumatism, scarlatinous, 297 
Rickets, 179 
Roseola, 879 

symptoms, causes, prognosis, diagnosis, 

880 
treatment, 881 
Rotheln, 328 



Rotheln: premonitory stage, 330 

symptoms, (a) tegumentary system, 330 
(6) mucous membrane, 331 
respiratory and digestive system, 331 
pulse, temperature, 332 
complications, prognosis, 332 
nature, incubative period, contagious- 
ness, 332-335 
complications, diagnosis, 335 
prognosis, treatment, 336 
Rubeola. (See Meades.) 

SCABIES, 890 
cause, 890 
diagnosis, 891 
treatment, 891, 892 
Scarlet fever, 271 
etiology, 271 
incubative period, 274 
contagiousness, 275 
variations in type, 276 
surgical scarlatina, 276 
obstetrical scarlatina, 279 
age, 280 
clinical facts regarding scarlet fever, 

281 
symptoms, ordinary form, 283 
grave form, 287 
irregular form, 288 
complications and sequelse, 289 
nervous accidents, 290 
inflammation of the faueial surface, 

291 
diphtheria, 293, 294 
inflammation of middle ear, 296 
scarlatinous rheumatism, 297 
pleuritis, 298 
dilation of the heart, 299 
nephritis, dropsy, 300 
parenchymatous nephritis, prolifera- 
tion of nuclei, 301 
interstitial nephritis, 303 
anatomical characters, 305 
diagnosis, 306 
prognosis, 308 
treatment, 310 
prophylaxis, 310 
hygienic, 313 
therapeutic, 313 
mild cases, 313 

ordinary and severe cases, 314 
antiseptic, 318 

complications and sequelse, 318, 
328 
Sclerema neonatorum, 174 
Scrofula, 205 
causes, 205 
• anatomical characters, 206 
dactylitis, 208 
symptoms, 209 
prognosis, 211 
treatment, 212 
Sepsis of new-born, 136 

first group, cases, 137, 140 
second group, cases, 140, 143 
third group, cases, 143, 145 



INDEX. 



899 



Skin diseases, 877 
Sleep in infancy, 82 
Smallpox, 336 
Spasm of the glottis, 590 
Spina bifida, 101 

diagnosis, prognosis, treatment, 102, 
103 
Spinal cord, diseases of, 634 
congestion of, 635 

anatomical characters, symptoms, 636 
treatment, 636, 637 
vertebral caries, 637_ 
Stomach, congestion of, 771 
inflammation of, 771 
dilatation of, 775 
softening of, 776 
Stomatitis, simple, 739 

causes, svmptoms, appearances, treat- 
ment, 739, 740 
Stomatitis, ulcerous, 740 

causes, svmptoms, prognosis, treatment, 
740", 741 
Stomatitis, aphthous, 742 

causes, symptoms, diagnosis, prognosis, 
treatment, 743 
Stomatitis, gangrenous, 744 
anatomical characters, 744 
causes, symptoms, 745 
diagnosis, 746 
prognosis, 747 
treatment, 748 
St. Vitus' or St. Guv's dance, 608 
Strophulus, 882 
varieties, 882 
treatment, 883 
Strumous ophthalmia, 217 
Syphilis, 251 
etiology, 251 
clinical history, 253 
coryza, mucous patches, 255 
roseola, pemphigus, acne, impetigo, ec- 
thyma, 256 
visceral lesions, 257 
osseous lesions, 258 
dactylitis syphilitica, 259 
prognosis, 259 
treatment, 260 

TAENIA solium, 826 
saginata, 827 
elliptica, 827 
Teething, 750 
Tetanus neonatorum, 159 
causes, 160 

period of commencement, 161 
frequency in certain localities, 162 
causes, 163 
symptoms, 170 

mode of death, prognosis, 171 
duration in fatal and favorable cases, 

172 
diagnosis, preventive treatment, 172, 

173 
treatment, 173, 174 
Tetany, 597 
causes, 597, 600 



Tetany : symptoms, 601 
cases, 602, 605 
pathology, diagnosis, 606 
prognosis, treatment, 607 
Thoracentesis, 728 
Thread-worms, 823 
Thrombosis in cranial sinuses, 527 
Thrush, 145 
causes, 145 

anatomical characters, 146 
symptoms, 147 
diagnosis, prognosis, 148 
treatment, 149 
j Tracheotomy, 675 
I Tubage in membranous croup, 668 
' Tuberculosis, 221 
I etiology, 221 
I anatomical characters, 224 
i in infancy and childhood, 225 

\ tubercles in lungs, 226 
\ cavities, emphysema, 228 

tubercles in abdominal viscera, 230 
stomacli and intestines, 230 
I general symptoms, 231 
encephalon, 232 

in tubercles of bronchial glands, 234 
physical signs, 235 
in tubercles of pleura, 237 
in tubercles of stomach and intestines, 237 
diagnosis, 237 
prognosis, 240 
prophylaxis, 241 
treatment, 243 
Typhlitis, 856 
Typhoid fever, 456 
causation, 456 
anatomical characters, 459 
pathology, 460 

incubative period, symptoms, 461 
duration, 462 
complications, 463 
diagnosis, 464 
prognosis, 465 
treatment, 465-469 
prophylaxis, 469, 470 

ULCEEOUS stomatitis, 740 
Umbilicus, diseases of, 127 
vegetations of, 127 

prognosis, diagnosis, treatment. 128 
hemorrhage of, 128 

sex, age, causes, 129, 130 
svmptoms, prognosis, treatment, 131, 
132 
Uric-acid infarctions, 866 
Urine, incontinence of, 870 
Urticaria, 881 

causes, diagnosis, prognosis, treatment, 
881 

VACCINIA, 345 
appearances, symptoms, 348 
anomalies, complications, sequels. 349 
erysipelas, syphilis, 349, 350 
subsequent vaccinations, 350 
protection from vaccination, 351 



900 



INDEX. 



Vaccinia : selection of virus, 352 
Varicella, 353 

symptoms, 354 

diagnosis, prognosis, treatment, 355 
Variola, 336 

etiology, 336 

incubative period, stage of invasion, 337 

stage of eruption, 338 
of desiccation, 338 
of desquamation, 339 
Varioloid, 340 

mode of death, 340 

anatomical characters, 341 

complications, 341 

diagnosis, 342 

treatment, 343 
Vaughan, Dr. V. C, remarks on intestinal 

bacteria, 781 
Vertebral caries, 637 
Vulvitis, 875 

etiology, 875 

treatment, 876 



w 



EANING, 62 

Weight of infant, 43 



', Wet-nurse, selection of, 59 
syphilis in, 59 
character of good milk, 60 
lactometer, 60 
lactoscope, 60 
use of microscope, 60 
! micro-organisms in milk, 60, 61 
I return of cataraenia, 61 
I course of wet-nursing, 62 
weighing of infant, 63 
Whooping-cough, 431 
I Worms, intestinal, 822 

ascaris lumbricoides. 823 
oxyuris vermicularis. 824 
tape-worm, 825 
taenia solium, 826 
taenia saginata, 827 
taenia elliptica, 827 
i bothriocephalus latus, 828 

I trichocephalus dispar, 828 

i causes, 829 

symptoms of ascaris lumbricoides, 830 
of oxyuris vermicularis, 831 
of tape-worm, 831 
diagnosis, prognosis, treatment, 832 



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Lea Brothers & Co.'s Publications — Period,, Manuals. 3 

TMB MBDICAL JSTJEWS VISITING LIST FOB 1890 

Has been revised and brought thorouglily up to date in every respect. It con- 
tains 48 pages of text, including calendar for two years; obstetric diagrams; scheme 
of dentition ; tables of weights and measures and comparative scales ; instructions for ex- 
amining the urine ; list of disinfectants ; table of eruptive fevers ; lists of new remedies 
and remedies not generally used ; incompatibles, poisons and antidotes ; artificial respira- 
tion ; table of doses, prepared to accord with tlie last revision of the U. S. Pharmacopoeia ; 
an extended table of Diseases and their remedies, and directions for ligation of ar- 
teries. 176 pages of blanks for all records of practice and erasable tablet. Handsomely 
bound in limp Morocco, with pocket, pencil, rubber and catheter scale. 

The Medical News Visiting List for 1890 is issued in three styles, as heretofore: 
Weekly (for 30 patients) ; Monthly, and Perpetual. Each in one volume, $1.25. Also 
furnished with Heady Keference Thumb-letter Index for quick use, 25 cents extra. For 
special offers, including Visiting List, see pages 1 and 2. 

This list is all that could be desired. It con- I list of diseases arranged alphabetically, giving 
tains a vast amount of useful infornnation, especi- under each a list of the prominent drugs em- 
ally for emergencies, and gives good table of doses ployed in the treatment. When ordered, a Ready 
and therapeutics.— Canadian Practitioner. | Reference Thumb-letter Index is furnished. This 

It is a masterpiece. Some of the features are i is a feature peculiar to this Visiting List. — Physi- 
peculiar to "The Medical News Visiting List," i dan and Surgeon, Becemher. 

notably the Therapeutic Table, prepared from Dr. j For convenience and elegance it is not surpass- 
T. Lauder Brunton's book, which contains the i able. — Obstetric Gazette November. 



TSU MEDICAL NEWS PHYSICIANS' LEDGEB. 

Containing 400 pages of fine linen " ledger "_ paper, ruled so that all the accounts of a 
large practice may be conveniently kept in it, either by single or double entry, for a long 
period. Strongly bound in leather, with cloth sides, and with a patent flexible back, 
which permits it to lie perfectly flat when opened at any place. Price, $5.00. AlsOj 
a small special lot of same Ledger, with 300 pages. Price, $4.00. 



HABTSSOBNE, MENBT, A. M., M. D., LL. !>., 

Lately Professor of Hygiene in the University of Pennsylvania. 

A Conspectus of the Medical Sciences ; Containing Handbooks on Anatomy, 
Physiology, Chemistry, Materia Medica, Practice of ^Medicine, Surgery and Obstetrics. 
Second edition, thoroughly revised and greatly improved. In one large royal 12iao. 
volume of 1028 pages, with 477 illustrations. Cloth, $4.25 ; leather, $5.00. 



The object of this manual is to afford a conven- 
ient work of reference to students during the brief 
moments at their command while in attendance 
upon medical lectures. It is a favorable sign that 
it has been found necessary, in a short space of 
time, to issue a new and carefully revised edition. 
The illustrations are very numerous and unusu- 



industry and energy of its able editor.— Boston 
Medical and Surgical Journal, Sept. 3, 1874. 

We can say with the strictest truth that it is the 
best work of the kind with which we are ac- 
quainted. It embodies in a condensed form all 
recent contributions to practical medicine, and i* 
therefore useful to every ousy practitioner through- 



ally clear, and each part seems to have received; out our country, besides being admirably adapted 
its due share of attention. We can conceive such i to the use of students of medicine. The book is 
a work to be useful, not only to students, but t0| faithfully and ably executed.— C/iar^eston Medical 
practitioners as well. It reflects credit upon the | Journal, April, 1875. 



NEILL, JOSN, M. D., and SMITH, F. G., M. !>., 

Late Surgeon to the Penna. Hospital. Prof, of the Institutes of Med. in the Univ. of Penna. 

An Analytical Compendium of the Various Branches of Medical 
Science, for the use and examination of Students. A new edition, revised and improved. 
In one large royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, $4; leather, $4.75. 



LUnLOW, J.L.,M.I>., 

Consulting Physician to the Philadelphia Hospital, etc. 

A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice o i 
Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which 
is added a Medical Formulary. Third edition, thoroughly revised, and greatly enlarged. In. 
one 12mo. volume of 816 pages, with 370 illustrations. Cloth, $3.25 ; leather, $3.75. 

The arrangement of this volume in the form of question and answer renders it espe- 
cially suitable for the oflice examination of students, and for those preparing for graduation. 

HOBLTN, BICHABH D., M. H. 

A Dictionary of the Terms Used in Medicine and the Collateral 
Sciences. Eevised, with numerous additions, by Isaac Hays, M. D., late editor of 
The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 
double-columned pages. Cloth, $1.50 ; leather, $2.00. 

It is the best book of definitions we have, and ought always to be upon the student's table.— <S'out^ertfe 
Medical and Surgical Journal. 



Lea Brothers & Co.'s Publications — Dictionaries. 



JUST READY 



THE^ 



n^TionAL IHgdkjal Di(z;TionAKY 



INCLUDING 



English, French, German, Italian and Latin Technical Terms used in Medicine and 
the Collateral Sciences, and a Series of Tables of Useful Data. 

BY 

John $. Billings, IJ.D,, LL.D, Ediq. and Haiiv., D.C.L, Oj^oq. 

Member of the National Academy of Sciences, Surgeon U. S. A., etc. 
WITH THE COLLABORATION OF 



Prof. W. O. ATWATER, JAMES M. FLINT, M. D. 

FRANK BAKER, M. D., J. H. KIDDER, M. D., 

S. M. BURNETT, M. D., WILLIAM LEE, M.D., 

W. T. COUNCILMAN, M. D., R. LORINI, M.D., 



WASHINGTON MATTHEWS, M. D., 
C. S. MINOT, M. D. 
H. C. YARROW, M. D., 



In two very handsome royal octavo volumes containing 1574 pages, 
with two colored plates. 

Per Volume— Cloth, $6; ZeatJier, $7; Bat f Morocco, Marbled Edges, $8.50. For Sale 
by Subscription only. Specimen pages on application. Address the Publishers. 



The publishers have great pleasure in presenting to the profession a new practical 
working dictionary embracing in one alphabet all current terms used in every depart- 
ment of medicine in the five great languages constituting modern medical literature. 

For the vast and complex labor involved in such an undertaking no one better quali- 
fied than Dr. Billings could have been selected. He has planned the work, chosen the 
most accomplished men to assist him in special departments, and personally supervised 
and combined their work into a consistent and uniform whole. 

Special care has been taken to render the definitions clear, sharp and concise. 
Pronunciation has been indicated by a simple phonetic spelling and by accents wherever 
necessary. The definitions are given in English, with synonyms in French, German 
and Italian of the more important words in English and Latin. 

Regarded as a dictionary, therefore, this coming standard supplies the physician, 
surgeon and specialist with all information concerning medical words, simple and com- 
pound, found in English, giving correct spelling, clear, sharp definitions and proper 
pronunciation, and furthermore it enables him to consult foreign works and to understand 
the large and increasing number of foreign words used in medical English. It is especi- 
ally full in phrases comprising two, three or more words used in special senses in the 
various departments of medicine. 

The work is, however, far more than a dictionary, and partakes of the nature of an 
encyclopaedia, as it gives in its body a large amount of valuable therapeutical and chemi- 
cal information, and groups in its tables, in a condensed and convenient form, a vast 
amount of important data which will be consulted daily by all in active practice. 

The completeness of the work is made evident by the fact that it defines 84,844 
separate words and phrases. 

The type has been most carefully selected for boldness and clearness, and everything 
has been done to secure ease and rapidity in use. 

Its scope is one which will at once satisfy the 
student and meet all the requirements of the med- 
i cal practitioner. Clear and comprehensive defi- 
nitions of words should form the prime feature of 
any dictionary, and in this one the chief aim 
seems to be to give the exact signification and the 
different meanings of terms in use in medicine 
and the collateral sciences in language as terse as 
is compatible with lucidity. The utmost brevity 
and conciseness have been kept in view. The work 
is remarkable, too, for its fulness. The enumera- 
tions and subdivisions under each word heading 
are strikingly complete, as regards alike the Eng- 
lish tongue and the languages chiefly employed 
by ancient and modern science. It is impossible 
t o do justice to the dictionary by any casual illus 
fc ration. It presents to the English reader a 
t horoughly scientific mode of acquiring a rich 
vocabulary and oflfers an accurate and ready means 
of reference in consulting works in any of the 



three modern continental languages which are 
richest in medical literature. To add to its use- 
fulness as a work of reference some valuable 
tables are given. Another feature of the work is 
the accuracy of its definitions, all of which have 
been checked by comparison with many other 
standard works in the different languages it deals 
with. Apart from the boundless stores of informa- 
tion which may be gained by the study of a good 
dictionary, one is enabled by the work under notice 
to read intelligently any technical treatise in any 
of the four chief modern languages. There can- 
not be two opinions as to the great value and use- 
fulness of this dictionary as a Dook of ready refer- 
ence for all sorts and conditions of medical men. 
So far as we have been able to see, no subject has 
been omitted, and in respect of completeness it will 
be found distinctly superior to any medical lexicon 
yet published. — The London Lancet, April 5, 1890. 



Lea Brothers & Co.'s Publications — Anatomy. 5 

GBAT, JECBI^ItY, F. B. S., 

Lecturer on Anatomy at St. Oeorge^s Hospital, London. 

Anatomy, Descriptive and Surgical. Edited by T. Pickering Pick, 
F. E, C, S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, 
Examiner in Anatomy, Eoyal College of Surgeons of England. A new American from 
the eleventh enlarged and improved London edition, thoroughly revised and re-edited 
by William W. Keen, M. D., Professor of Surgery in the Jefferson Medical College of 
Philadelphia. To which is added the second American from the latest English edition of 
Landmarks, Medical and Surgical, by Luther Holden, F. R. C. S. In one imperial 
octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Price of 
edition in black : Cloth, $6 ; leather, $7 ; half Russia, $7.50. Price of edition in colors 
(see below) . Cloth, $7.25; leather, $8.25; half Russia, $8.75. 

This work covers a more extended range of subjects than is customary in the ordinary 
text-books, giving not only the details necessary for the student, but also the application to 
those details to the practice of medicine and surgery. It thus forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engravings 
form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. In this edition a new departure 
has been taken by the issue of the work with the arteries, veins and nerves distinguished 
by different colors. The engravings thus form a complete and splendid series, which will 
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recall- 
ing the details of the dissecting-room. Combining, as it does, a complete Atlas of 
Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, 
the work will be found of great service to all physicians who receive students in their 
oflices, relieving both preceptor and pupil of much labor in laying the groundwork of a 
thorough medical education. 

For the convenience of those who prefer not to pay the slight increase in cost necessi- 
tated by the use of colors, the volume is published also in black alone, and maintained 
in this style at the price of former editions, notwithstanding its largely increased size. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, 
has been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. 

The most popular work on anatomy ever written. I books. The work is published with black and 
It is sufficient to say of it that this edition, thanks i colored plates. It is a marvel of book-making. — 
to its American editor, surpasses all other edi- ! American Practitioner and News, Jan. 21,1888. 
tions. — Jour, of the Amer. Med. Ass'n, Dec. 31, 1887. ' Gray's Anatomy is the most magnificent work 

A work which for more than twenty years has \ upon anatomy which has ever been published in 
had the lead of all other text-books on anatomy ; the English or any other language.— CiHcinrea^i 
throughout the civilized world comes to hand in i Medical News, Nov. 1887. 

such oeauty of execution and accuracy of text , As the book now goes to the purchaser he is re- 
and illustration as more than to make good the ceiving the best work on anatomy that is published 
large promise of the prospectus. It would be in- ia any language.— FiryintaJl/e^i. Monthly, Dec. 1887. 
deed difficult to name a feature wherein the pres- Gray's standard Anatomy has been "and will be 
ent American edition of Gray could be mended for years the text-book for students. The book 



or bettered, and it needs no prophet to see that needs only to be_examined_to be perfectly under- 
yal work is destined for many years to come stooc" 
Id the first place among anatomical text- . 1888. 



the royal work is destined for many years to come stood.— Medical Press of Western New ForA;, Jan. 
to hold 



Also for sale separate — 
SOLI) JEW, LVTJSBB, F. B. C. S., 

Surgeon to St. Bartholomew's and the Foundling Hospitals, London. 

Landmarks, Medical and Surgical. Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
the Penn. AcaJecny of Fine Arts. In one 12aio. volume of 148 pages. Cloth, $1.00 



BJJNaLISOW, BOBLFY, M. D., 

Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science : Containing 

a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- 
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- 
prudence and Dentistry, Notices of Climate and of Minerah Waters, Formulae for Officinal, 
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, 
and the French and other Synonymes, so as to constitute a French as well as an English 
Medical Lexicon. Edited by Richard J. Du:n^glison, M. D. In one very large and 
handsome royal octavo volume of 1139 pages. Cloth, $6.50; leather, raised bands, $7.50; 
very handsome half Russia^ raised bands, $8. 

It has the rare merit that it certainly has no rival in the English language for accuracy 
and extent of references.— iondora Medical Gazette. 



Lea Brothers & Co.'s Publications — Anatomy. 



ALLBJSr, MAItltlSOJV, M. 2>., 

Professor of Physiology in the University of Pennsylvania. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Section I. Histology. 
Section II. Bones and Joints. Section III. Muscles and Fascia. Section IV. 
Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. 
Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology, 
Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, 
AND General and Clinical Indexes. Price per Section, $3.50 ; also bound in one 
volume, cloth, $23.00 ; very handsome half Kussia, raised bands and open back, $25.00. 
For sale by subscription only. Apply to the Publishers. 



It is to De considered a study of applied anatomy 
In its Widest sense — a systematic presentation of 
such anatomical facts as can be applied to the 
practice of medicine as well as of surgeiy. Our 
author is concise, accurate and practical in his 
statements, and succeeds admirably in infusing 
an interest into the study of what is generally con- 
sidered a dry subject. The department of Histol- 
ogy is treated in a masterly manner, and the 
ground is travelled over by one thoroughly famil- 
iar with it. The illustrations are made with great 



care, and are simply superb. There is as much 
of practical application of anatomical points to 
the every-day wants of the medical clinician as 
to those of the operating surgeon. In fact, few 
general practitioners will read the work without a 
feeling of surprised gratification that so many 
points, concerning which they may never have 
thought before are so well presented for their con- 
sideration. It is a work which is destined to be 
the best of its kind in any language. — Medical 
Record, Nov. 25, 1882. 



CLABKJE, W. B., F.M. C.S. <& LOCKWOOI), C. B., F.B. C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 
The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 31. 

Messrs.Clarke and Lockwood have written a book I intimate association with students could have 
that can hardly be rivalled as a practical aid to the , given. With such a guide as this, accompanied 
dissector. Their purpose, which is " how to de- ! by so attractive a commentary as Treves' Surgical 
scribe the best way to display the anatomical I Applied Anatomy (same series), no student could 
structure," has been fully attained. They excel in j fail to be deeply and absorbingly interested in the 
a lucidity of demonstration and graphic terseness j study of anatomy.— iV^ew; Orleans Medical and Sur- 
of expression, which only a long training and | gical Journal, April, 1884. 



TBBVBS, FBBnEBICK, F. B. C. S,, 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. 
Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, 
with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals^ 
page 31. 

He has produced a work which will command a 
larger circle of readers than the class for which it 
was written. This union of a thorough, practical 
acquaintance with these fundamental branches, 
quickened by daily use as a teacher and practi- 
tioner, has enabled our author to prepare a work 
which it would be a most difficult task to excel.— 
The American Practitioner, Feb. 1884. 



This number of the "Manuals for Students" is 
most excellent, giving just such practical knowl- 
edge as will be required for application in relieving 
the injuries to which the living body is liable. 
The book is intended mainly for students, but it 
will also be of great use to practitioners. The illus- 
trations are well executed and fully elucidate the 
text.— Southern Practitioner, Feb. 1884. 



BBLLAMY, BDWABD, F. B. C. S., 

Senior Assistant-Surgeon to the Charing- Cross Hospital, London. 

The Student's Guide to Surgical Anatomy : Being a Description of the 
most Important Surgical Regions of the Human Body, and intended as an Introduction to 
operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. 

WILSON, BBASMUS, F. B. S. 

A System of Human Anatomy, General and Special. Edited by W. H. 
Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00; leather, $5.00. 

CLBLANB, JOMW, M. D., F. B. S., 

Professor of Anatomy and Physiology in Queen's College, Galway. 

A Directory for the Dissection of the Human Body. 

volume of 178 pages. Cloth, $1.25. 



In one 12mo. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
In one royal 12mo. volume of 310 pages, with 220 
woodcuts. Cloth, $1.75. 



HORNER'S SPECIAL ANATOMY AND HISTOL- 
OGY. Eighth edition, extensively revised and 
modified. In two octavo volumes of 1007 page&, 
with 320 woodcuts. Cloth, 86.00. 



Lea Brothers & Co. s Publications — Physics, Pliysiol.,Anat. 7 
DB^ABBH^, JOMJS^ C, M. D., LL. D., 

Professor of Chemistry in the University of the City of New York. 
Medical Physics. A Text-book for Students and Practitioners of Medicine. In 
one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 

FROM THE PREFACE. 

The fact that a knowledge of Physics is indispensable to a thorough understanding of 
Medicine has not been as fully realized in this country as in Europe, where the admirable 
works of Desplats and Gariel, of Kobertson and of numerous German writers constitute a 
branch of educational literature to which we can show no parallel. A full appreciation 
of this the author trusts will be sufficient justification for placing in book form the sub- 
stance of his lectures on this department of science, delivered during many years at the 
University of the City of New York. 

Broadly speaking, this work aims to impart a knowledge of the relations existing 
between Physics and Medicine in their latest state of development, and to embody in the 
pursuit of this object whatever experience the author has gained during a long period of 
teaching this special branch of applied science. 

This elegant and useful work bears ample testi- I explained, acoustics, optics, heat, electricity and 
mony to the learning and good judgment of the | magnetism, closing with a section on electro- 
author. He has fitted his work admirably to the ! biology. The applications of all these to physiology 
exigencies of the situation by presenting the i and medicine are kept constantly in view. The 
reader with brief, clear and simple statements of , text is amply illustrated and the many difficult 
such propositions as he is by necessity required to points of the subject are brought forward with re- 
master. The subject matter is well arranged, j markable clearness and ability. — Medical and Surg- 
liberally illustrated and carefully indexed. That ' ical Reporter, July 18, 1885. 

it will take rank at once among the text-books is That this work will greatly facilitate the study 
certain, and it is to be hoped that it will find a I of medical physics is apparent upon even a mere 
place upon the shelf of the practical physician, ' cursory examination. It is marked by that scien- 
where, as a book of reference, it will be found j tific accuracy which always characterizes Dr. 



useful and agreeabl®. — Louisville Medical News, 
Septemoer 26, 1885. 

Certainly we have no text-book as full as the ex- 
cellent one he has prepared. It begins with a 
statement of the properties of matter and energy. 
After these the special departments of physics are 



Draper's writings. Its peculiar value lies in the 
fact that it is written from the standpoint of the 
medical man. Hence much is omitted that ap- 
pears in a mere treatise on physical science, while 
much is inserted of peculiar value to the physi- 
cian.— iWedica^ Record, August 22, 1885. 



BOBEBTSOl^, J. McGHBGOB, M. A., M. B., 

Muirhead Demonstrator of Physiology, University of Glasgow. 

Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- 
tions. Limp cloth, $2.00. See Students^ Series of Manuals, page 31. 

The title of this work sufficiently explains the ! ments. It will be found of great value to the 
nature of its contents. It is designed as a man- | practitioner. It is a carefully prepared book of 
ual for the student of medicine, an auxiliary to ' reference, concise and accurate, and as such we 
his text-book in physiology, and it would be particu- ' heartily recommend it. — Journal of the American 
larly useful as a guide to his laboratory experi- | Medical Association, Dec. 6. 1884. 

DAZTOW, JOSJSr C, M. D., 

Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York. 

Doctrines of the Circulation of the Blood. A History of Physiological 
Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 
12mo. volume of 293 pages. Cloth, $2. 

Dr. Dalton's work is the fruit of the deep research ! revolutionized the theories of teachers, than the 
of a cultured mind, and to the busy practitioner it discovery of the circulation of the blood. This 
cannot fail to be a source of instruction. It will explains the extraordinary interest it has to all 
Inspire him with a feeling of gratitude and admir- medical historians. The volume before us is one 
ation for those plodding workers of olden times, of three or four which have been written within a 
who laid the foundation of the magnificent temple few years by American physicians. It is in several 
of medical science as it now stands.— ZVew; Orleans , respects the most complete. The volume, though 
Medical and Surgical Journal, Aug. 1885. small in size, is one of the most creditable con- 

In the progress of physiological study no fact tributionsfroman American pen to medical history 
was of greater moment, none more completely that has appeared. — Med. d: Surg. Rep., Dec. 6, 1884. 

BBLL, F. JEFFREY, 31. A., 

Professor of Comparative Anatomy at King's College, London. 

Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages, 
with 229 illustrations. Limp cloth, $2.00. See Students^ Series of Manuals, page 31. 

The manual is preeminently a student's book — ! it the best work in existence in the English 
clear and simple in language and arrangement, language to place in the hands of the medical 
It is well and abundantly illustrated, and is read- student. — Bristol Medico- Chirurgical Journal, Mar. 
able and interesting. On the whole we consider 1886. 

ELLIS, GEOBGE VIWEB, 

Emeritus Professor of Anatomy in University College, London. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. From the eighth and revised London edition. In one very 
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather, $5.25. 

BOBEBTS, JOHN B., A. M,, M. I)., 

Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic and Coll. or Graduates in Medicine. 
The Compend of Anatomy. For use in the dissecting-room and in preparing 
for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. 



8 Lea Brothers & Co.'s Publications — Physiology, Chemistry. 



CEEABMAW, SBWUY C, M. !>., 

Professor of Institutes of Medicine and Medical Juris, in the Jefferson Med. Coll. of Philadelphia. 

A Treatise on Human Physiology. In one handsome octavo volume of 
925 pages, with 605 fine engravings. Cloth, |5.50 ; leather, $6.50. 



It represents very fully the existing state of 
physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical find Surgical Journal, Dec. 1887. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 
nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no 



farther, and the latter will find entertainment and 
instruction in an admirable book of reference. — 
North Carolina Medical Journal, Nov. 1887. 

The work certainly commends itself to both 
student and practitioner. What is most demanded 
by the progressive physician of to-day is an adap- 
tation of physiology to practical therapeutics, and 
this work is a decided improvement in this respect 
over other works in the market. It will certainly 
take place among the most valuable text-books. — 
Medical Age, Nov. 25, 1887. 

It is the production of an author delighted with 
his work, and able to inspire students with an en- 
thusiasm akin to his own. — American Practitioner 
and News, Nov. 12, 1887. 



DALTOJV, JOSW C, M. D., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc. 

A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00; leather, $6.00. 



From the first appearance of the book it has 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects. 
It must be gratifying to him to observe the fre- 
quency with which his work, written for students 
and piactitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



have never been in any doubt as to its sterling 
worth.— iV. Y. Medical Journal, Oct. 1882. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those branches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one which we can highly recommend to all our 
readers. — Dublin Journal of Medical Science, Feb.'83. 



FOSTBB, MICJEEABL, M. I)., F. B. S., 

Prelector in Physiology and Fellow of Trinity College, Cambridge, England. 
Text-Book of Physiology. New (fourth) and enlarged American from the 
fifth and revised English edition, with notes and additions. Preparing. 

A REVIEW OF THE FIFTH ENGLISH EDITION IS APPENDED. 

It is delightful to meet a book which deserves \ tions, and his energies are not frittered away and 
only unqualified praise. Such a book is now before 
us. It is in all respects an ideal text-book. With a 
complete, accurate and detailed knowledge of his 
subject, the author has* succeeded in giving a 
thoroughly consecutive and philosophic account 
of the science. A student's attention is kept 
throughout fixed on the great and salient ques- 



degenerated on petty and trivial details. Review- 
ing this volume as a whole we are justified in say- 
ing that it is the only thoroughly good text-book 
of physiology in the English language, and that it 
is probably the best text-book in any language. 
—Edinburgh Medical Journal, December 1889. 



JPOWFB, JErJEJSrBT, M. B., F. B. C. S., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- 
ume of 396 pp., with 47 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 31. 

SIMON, W., Fh. D., M. jD., 

Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimxyre, and 
Professor of Chemistry m the Maryland College of Pharmacy. 

Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
New (second) edition. In one 8vo. vol. of 478 pp., with 44 woodcuts and 7 colored plates 
illustrating 56 of the most important chemical tests. Cloth, $3.25. 

In this book the author has endeavored to meet 
the wants of the student of medicine or pharmacy 
in regard to his chemical studies, and he has suc- 
ceeded in presenting his subject so clearly that no 
one who really wishes to acquire a fair knowledge 
of chemistry can fail to do so with the help of this 
work. The largest section of the book is naturally 
that devoted to the consideration of the carbon 
compounds, or organic chemistry. An excellent 



feature is the introduction of a number of plates 
showing the various colors of the most important 
chemical reactions of the metallic salts, of some 
of the alkaloids, and of the urinary tests. In the 
part treating of physiological chemistry the section 
on analysis of the urine will be found very practi- 
cal, and well suited to the needs of the practitioner 
of medicine.-— T'/ie Medical Record, May 25, 1889. 



Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Iea Eemsen, M. D., Ph. D. In one 12m o. volume of 550 pages. Cloth, $3. 



LEHMANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, 82.25. 

CARPENTER'S HUMAN PHYSIOLOGY. Edited 
by Henky Power. In one octavo volume. 



CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquors in Health and Dis- 
EASE. With explanations of scientific words. Small 
12mo. 178 pages. Cloth, 60 cents. 



Lea Brothers & Co.'s Publications — Chemistry. 



fbankJjAnjd, b., n. a l., f. b.s., &jafjp, f. b., f. i, c. 

Assist. Prof, of Chemistry in the Normal 
School of Science, London. 



Professor of Chemistry in the Normal School 
of Science, London. 



Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 

woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 

This work should supersede other works of its 
class in the medical colleges. It is certainly better 
adapted than any work upon chemistry,with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 
chemical knowledge is behind the times, would 
do well to devote some of their leisure time to the 
study of this work. The descriptions and demon- 
strations are made so plain that there is no diffi- 
culty in understanding them. — Cincinnati Medical 
News, January, 1886. 



This excellent treatise will not fail to take its 
place as one of the very best on the subject of 
which it treats. We have been much pleased 
with the comprehensive and lucid manner in 
which the difficulties of chemical notation and 
nomenclature have been cleared up by the writers. 
It shows on every p)age that the problem of 
rendering the obscurities of this science easy 
of comprehension has long and successfully 
engaged the attention of the authors. — Medical 
and Surgical Reporter, October 31, 1885. 



FOWNFS, GEOBGF, Fh. D. 

A Manual of Elementary Chemistry; Theoretical and Practical. Em- 
bodying Watts' Physical Inorganic Chemistry. New American, from the twelfth English 
edition. In one large royal 12mo. volume of 1061 pages, with 168 illustrations on wood 
and a colored plate. Cloth, $2.75; leather, $3.25. 
Fownes' Chemistry has been a standard text- j chemistry extant. — Cincinnati Medical News, Oc- 



book upon chemistry for many j'^ears. Its merits 
are very fully known by chemists and phj'sicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has been revised so as to 
keep it abreast of the times. It has steadily- 
maintained its position as a textbook with medi- 
cal students. In this work are treated fully: Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 
work as one of the very best text-books upon 



tober, 1885. 

Of all the works on chemistry intended for the 
use of medical students, Fownes' Chemistry is 

Eerhaps the most widely used. Its popularity is 
ased upon its excellence. This last edition con- 
tains all of the material found in the previous, 
and it is also enriched by the addition of Watts^ 
Physical and Inorganic Chemistry. All of the mat- 
ter is brought to the present standpoint of chemi- 
cal knowledge. We may safely predict for this 
work a continuance of the fame and favor it enjoys 
among medical students.— lYew Orleans Medical 
and Surgical Journal, March, 1886. 



ATTFIELn, JOSN, Fh. D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
and their Application to Medicine and Pharmacy. A new American, from the twelfth 
English edition, specially revised by the Author for America. In one handsome royal 
12mo. volume of 782 pages, with 88 illustrations. Cloth, $2.75 ; leather, $3.25. Just ready. 



Attfield's Chemistry is the most popular book 
among students of medicine and phai macy. This 
popularity has a good, substantial basis. It rests 
upon real merits. Attfield's work combines in the 
happiest manner a clear exposition of the theory 
of chemistry with the practical application of this 
knowledge to the everyday dealings of the phy- 
sician and pharmacist. His discernment is shown 
not only in what he puts into his work, but also in 
what he leaves out. His book Is precisely what 
the title claims for it. The admirable arrangement 
of the text enables a reader to get a good idea of 
chemistry without the aid of experiments, and 



again it is a good laboratory guide, and finally it 
contains such a mass of well-arranged information 
that it will always serve as a handj"- book of refer- 
ence. He does not allow any unutilizable knowl- 
edge to slip into his book; his long years of 
experience have produced a work which is both 
scientific and practical, and which shuts out 
everything in tne nature of a superfluity, and 
therein lies the secret of its success. This last 
edition shows the marks of the latest progress 
made in chemistry and chemical teaching.— iV^eic 
Orleans Medical and Surgical Journal, Nov. 1889. 



BLOXAM, CJEABLFS L., 

Professor of Chemistry in King^s College, London. 

Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00. 

Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 
complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations ol 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 



the best manuals of general chemistry tn the Eng- 
lish language. — Detroit Lancet, Feb. 1884. 

We know of no treatise on chemistry which 
contains so much practical information in the 
same number of pages. The book can be readily 
adapted not only to the needs of those who desire 
a tolerably complete course of chemistry, but also 
to the needs of those who desire only a general 
knowledge of the subject. We take pleasure in 
recommending this work both as a satisfactory 
text- book, and as a useful book of reference.— JBos- 
ton Medical and Surgical Journal, June 19, 1884. 



GBEENE, WILLIAM M., M. D., 

Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. 
A Manual of Medical Chemistry. For the use of Students. Based upon Bow- 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 
It is a concise manual of three hundred pages, the recognition of compounds due to pathological 
giving an excellent summary of the best methods i conditions. The detection of poisons is treated 
of analyzing the liquids and solids of the body, both with sufficient fulness for the purpose of thestu- 
for the estimationof their normal constituent and 1 dent or practitioner. — Boston Jl. of Chem. June,'80. 



10 



Lea Brothers & Co.'s Publications — Chemistry, 



MBMSBW, IBA, M. D., JPh. JD., 

Professor of Chemistry in the Johns Hopkins University, Baltimore. 

Principles of Theoretical Chemistry, with special reference to the Constitu- 
tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- 
some royal 12mo. volume of 316 pages. Cloth, $2.00 



This work of Dr. Remsen is the very text-book 
needed, and the medical student who has it at 
his fingers' ends, so to speak, can, if he chooses, 
make himself familiar with any branch of chem- 
istry which he may desire to pursue. It would be 
difficult indeed to find a more lucid, full, and at 
the same time compact explication of the philos- 
ophy of chemistry, than the book before us, and 
we recommend it to the careful and impartial 



examination of college facalties as the text-book of 
chemical instruction. — St. Louis Medical and Sur- 
gical Journal, January, 1888. 

It is a healthful sign when we see a demand for 
a third edition of such a book as this. This edi- 
tion is larger than the last by about seventy-five 
pages, and much of it has been rewritten, thus 
bringing it fully abreast of the latest investiga- 
tions. — N. Y. Medical Journal, Dec. 31, 1887. 



CHABLBS, T. CBANSTOVN, M. D., F. C. S., M. S., 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen''s College, Belfast, 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination- in detail, and 
an outline syllabus of a practical course of instruction for students. In one handsome octavo 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, |3.50. 

nowadays. Dr. Charles has devoted much space 



Dr. Charles is fully impressed with the import- 
ance and practical reach of his subject, and he 
has treated it in a competent and instructive man- 
ner. We cannot recommend a better book than 
the present. In fact, it fills a gap in medical text- 
books, and that is a thing which can rarely be said 



to the elucidation of urinary mysteries. He does 
this with much detail, and yet in a practical and 
intelligible manner. In fact, the author has filled 
his book with many practical hints.— Medical Bee- 
ord, December 20, 1884. 



HOFFMAJ^N, F., A.3I., PJuD., & FOWFM F.B., Fh.D., 

Public Analyst to the State of New York. Prof, of Anal. Chem.in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

We congratulate the author on the appearance tion of them singularly explicit. Moreover, it is 
of the third edition of this work, published for the exceptionally free from typographical errors. We 
first time in this country also. It is admirable and have no hesitation in recommending it to those 
the information it undertakes to supply is both who are engaged either in the manufacture or the 
extensive and trustworthy. The selection of pro- testing of medicinal chemicals. — London Pharma- 
cesses for determining the purity of the substan- ceutical Journal and Transactions, 1883. 
ces of which it treats is excellent and the descrip- 



CLOWFS, FMAJVB:, n. Sc, London, 

Senior Science- Master at the High School, New castle-under -Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one very handsome royal 12mo. volume of 387 pages, with 55 illustrations. Cloth, 
$2.50. 

This work has long been a favorite with labora- 
tory instructors on account of its systematic plan, 
carrying the student step by step from the simplest 
questions of chemical analysis, to the more recon- 
dite problems. Features quite as commendable 
are the regularity and system demanded of the 



student in the performance of each analysis. 
These chaiacteristics are preserved in the present 
edition, which we can heartily recommend as a sat- 
isfactory guide for the student of inorganic chem- 
ical analysis. — New York Medical Journal, Oct. 9, 
1886 



BALFF, CSABLFS H., M. Z>., F. B. C. F., 

Assistant Physician at the London Hospital. 
Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 
illustrations. Limp cloth, red edges, $1.50. 
This is one of the most instructive little works 



that we have met with in a long time. The author 
is a physician and physiologist, as well as a chem- 
ist, consequently the book is unqualifiedly prac- 
tical, telling the physician just what he ought to 
know, of the applications of chemistry in medi- 



See Students' Series of Manuals, page 31. 
cine. Dr. Ralfe is thoroughly acquainted with the 
latest contributions to his science, and it is quite 
refreshing to find the subject dealt with so clearly 
and simply, yet in such evident harmony with the 
modern scientific methods and spirit. — Medical 
Becord, February 2, 1884. 



CLASSFJSr, ALFXAWnFB, 

Professor in the Boyal Polytechnic School, Aix-la-Chapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, by 
Edgar F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illus. Cloth, $2.00. 

It is probably the best manual of an elementary and then advancing to the analysis of ininerals and 
nature extant, insomuch as its methods are the such products as are met with in applied chemis- 
best. It teaches by examples, commencing with try. It is an indispensable book for students in 
single determinations, followed by separations, chemistry.— Boston Journal of Chemistry, Oct. 1878. 



Lea Brothers & Co.'s Publications — Pliarm., Mat. Med., Tlierap. 11 
BBVJS^TON, T. LAUDJEB, M.D., D.Sc, F.B.S., FM.C.B.^ 

Lecturer on Materia Medico, and Therapeutics at St. Bartholomew's Hospital, London, etc. 

A Text-book of Pharmacology, Therapeutics and Materia Mediea; 

Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
Third edition. Octavo, 1305 pa'ges, 230 illustrations. Cloth, S-d'.SO ; leather, $6.50. 

No word? of praise are needed for this woric, for : part?, has appeared during the life of the present 
it ha? already spoken for itself in former editions, generation. This is scrong language, but it is the 
It was by unanimous consent placed among the truth. The great merit of this work is that the 
foremost books on the subject ever published in author has been able so well to coordinate facts 
anylanguage,andthebetteritis known andstudied into an intelligible and rational system of pharma- 
the more highly it is appreciated. The present ' cology, and henceforth no treatise on therapeutics 
edition contains much new matter, the insertion will be considered complete which does not in 
of which has been necessitated by the advances some measure adopt this method. The busy 
made in various directions in the art of therapeu- physician will approach this book to learn some- 
tics, and it now stands unrivalled in its thoroughly \ ihing that will better fit him for his work, and on 
scientific presentation of the modes of drug action, everj' page he will find something that will reward 
No one who wishes to be fQll}' up to the times in him for the time spent in its perusal. We com- 
thls science can afford to neglect the study of Dr. mend this book as one which every physician 
Brunton's work. The indexes are excellent, and '. should own and study. It is a worli w'hich if once 
add not a little to the practical value of the book, i owned will be likely to be read and consulted till 
—Medical Record, May 25, 1889. i the covers fall off from much nse.— Boston Medical 

Nothing so original and so complete on the action I and Surgical Journal, Dec. 20, 1888. 
of drugs on the body generally and on its various ' 



HABB, SOB ART AMD BY, B, Sc, M. D., 

Demonstrator of Therapeutics and Clinical Professor of Diseases of Children in the University of 
Pennsylvania; Secretary of the Convention for the Revision of the United States Pharmacopceia of 

1890. 

A Text-Book of Practical Therapeutics ; With Especial Reference to the 
Application of Eemedial Measures to Disease and their Employment upon a Rational 
Basis. With special chapters bj Drs. G. E. de Schweinitz, Edward Martin, 
J. Howard Reeves and Barton C. Hirst, in one handsome octavo volume of about 
700 pages. Shortly. 

The publishers take great pleasure in announcing the early appearance of a new work 
on Therapeutics, planned on lines which will secure for it a leading position as a text-book 
and work of reference. The author's large experience in experimental, didactic and 
clinical work, has peculiarly fitted him to produce a volume containing all that is latest 
and best in the application of remedial measures, and to present this material in a way 
which will not only impress it into the mind of the student firmly, because rationally, 
but which will also render it of daily service to practitioners by reason of its definite 
instructions as to the choice of various agents which may be employed. 

MAISCH, JOMWM., Bhar. JX, 

Professor of Materia Mediea and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Mediea; Being a Guide to Materia Mediea of 
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists 
and Physicians. New r4th) edition, thoroughly revised. In one handsome royal 12mo. 
volume of 529 pages, with 258 illustrations. Cloth, §3. Just ready. 

For everyone interested in materia mediea, ' fore his eyes. That it answers its purposes in this 
Maisch's Manual, first published in 1882, and now respect the rapid succession of editions is the best 
in its fourth edition, is an indispensible book. , evidence. It is the favorite book of the American 
For the American pharmaceutical student it is ' student even outside of ^Maisch's several hundred 
the work which will give him the necessary knowl- ' personal students. The arrangement of its con- 
edge in the easiest way, partly because the text is ^ tents shows the practical tendency of the book, 
brief, concise, and free from unnecessary matter, j 3Iaisch's system of classification is easy and com- 
and partly because of the numerous illustrations, prehensive. — Pharmaceutische Zeitung, Germany, 



1^ 



which bring facts worth knowing immediately be- \ 1890. 



BABBISBL, EJJWABn, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. 
A Treatise on Pharmacy : designed as a Text-book for the Student, and as a 
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, $6. 

No thorough-going pharmacist will fail to possess ods of combination are concerned, can afford to 
himself of so useful a guide to practice, and no leave this work out of the list of their works of 
physician who properly estimates the value of an reference. The country practitioner, who must 
accurate knowledge of the remedial agents em- ' always be in a measure his own pharmacist, will 
ployed by him in daily practice, so far as their find it indispensable. — Louisville Medical News, 
miscibility, compatibility and most effective meth- March 29, 1884. 



SJEB3IAlNW, JDr. L., 

Professor of Physiology in the University of Zurich. 
Experimental Pharmacology. A Handbook of Methods for Determining the 
Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Kobert Meade Smith, M. D., Demonstrator of Physiology in the 
University of Pennsylvania. 12mo., 199 pages, with 32 illustrations. Cloth, $1.50. 

STILLJE, ALFBJEJD, M. JD., LL. !>., 

Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 

Therapeutics and Materia Mediea. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, including their Description and History. Fourth edition, 
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages. 
Cloth, $10.00; leather, $12.00. 



12 Lea Brothers & Co.'s Publications — Mat. Med., Tlierap. 



8TILLB, A., M.n.^LL.JD., & MAISCS, J. M.,jPhar.n., 



Professor Emeritus of the Theory and Prac- 
tice of Medicine and of Clinical Medicine 
in the University of Pennsylvania. 



Prof, of Mat. Med. and Botany in Phila. 
College of Pharmacy, Sec' y to the Ameri- 
can Pharmaceutical Association. 



The National Dispensatory. 

CONTAINING THE NATURAL HISTORY, CHEMISTRY. PHARMACY, ACTIONS AND USES OF 

MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPEIAS OF THE 

UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS 

REFERENCES TO THE FRENCH CODEX. 

Fourth edition revised, and covering the new British Pharmacopoeia. In one mag- 
nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings. Price 
in cloth, $7.25 ; leather, raised bands, |8.00. *^^This work will be furnished with Patent 
Ready Reference Thumb-letter Index for $1.00 in addition to the price in any style of binding. 

In this new edition of The National Dispensatory, all important changes in the 
recent British Pharmacopoeia have been incorporated throughout the volume, while in 
the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical 
novelties which have been established in professional favor since the publication of the 
third edition two years ago. Since its first publication, The National Dispensatory 
has been the most accurate work of its kind, and in this edition, as always before, it may 
be said to be the representative of the most recent state of American, English, German 
and French Pharmacology, Therapeutics and Materia Medica. 



It is with much pleasure that the fourth edition 
of this magnificent work is received. The authors 
and publishers have reason to feel proud of this, 
the most comprehensive, elaborate and accurate 
work of the kind ever printed in this country. It 
is no wonder that it has become the standard au- 
thority for both the medical and pharmaceutical 
profession, and that four editions have been re- 
quired to supply the constant and increasing 
demand since its first appearance in 1879. The 
entire field has been gone over and the various 
articles revised in accordance with the latest 
developments regarding the attributes and thera- 
peutical action of drugs. The remedies of recent 



discovery have received due attention. — Kansas 
City Medical Index, Nov. 1887. 

We think it a matter for congratulation that the 
profession of medicine and that of pharmacy have 
shown such appreciation of this great work as to call 
for four editions within the comparatively briel 
period of eight years. The matters with which it 
deals are of so practical a nature that neither the 
physician nor the pharmacist can do without the 
latest text-books on them, especially those that are 
so accurate and comprehensive as this one. The 
book is in every way creditable both to the authors 
and to the publishers. — New York Medical Journal^ 
May 21, 1887. 



FABQUSABSOW, BOBEBT, M. D., F. B. C. B., LL. D., 

Lecturer on Materia Medica at St. Mary's Hospital Medical School, London. 

A Guide to Therapeutics and Materia Medica. New (fourth) American, 
from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia. By 
Frank Woodbury, M. D., Professor of Materia Medica and Therapeutics and Clinical 
Medicine in the Medico-Chirurgical College of Philadelphia. In one handsome 12mo. 
volume of 581 pages. Cloth, $2.50 



It may correctly be regarded as the most modern 
work of its kind. It is concise, yet complete. 
Containing an account of all remedies that have 
a place in the British and United States Pharma- 
copcBias, as well as considering all non-official but 
important new drugs, it becomes in fact a miniature 
dispensatory. — Pacific Medical Journal, June, 1859. 

An especially attractive feature is an arrange 
mentby which the physiological and therapeutical 



actions of various remedies are shown in parallel 
columns. This aids greatly in fixing attention and 
facilitates study. The American editor has en- 
larged the work so as to make it include all the 
remedies and preparations in the U. S. Pharma- 
copoeia. The book is a most valuable addition to 
the list of treatises on this most important subject. 
— American Practitioner and News, Nov. 9th, 1889. 



JEDBS, BOBBBT T., M. B., 

Jackson Professor of Clinical Medicine in Harvard University, Medical Department. 

A Text-Book of Therapeutics and Materia Medica. Intended for the 



Use of Students and Practitioners. Octavo, 
The present work seems destined to take a prom- 
inent place as a text-book on the subjects of which 
it treats. It possesses all the essentials which we 
expect in a book of its kind, such as conciseness, 
clearness, a judicious classification, and a reason- 
able degree of dogmatism. All the newest drugs 
of promise are treated ol. The clinical index at 
the end will be found very useful. We heartily 



544 pages. Cloth, $3.50 ; leather, $4.50. 
commend the book and congratulate the author 
on having produced so good a one.— iV. Y. Medical 
Journal, Feb. 18, 1888. 

Dr. Edes' book represents better than any older 
book the practical therapeutics of the present- 
day. The book is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic action.— Pharmaceutical Era, Jan. 1888. 



BBUCB, J. MITCSBLL, M. B., B. B. C. B., 

Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London, 

Materia Medica and Therapeutics. An Introduction to Eational Treatment. 
Fourth edition. 12mo., 591 pages. Cloth, $1.50. See Student^ Series of Manuals, page 31. 

GBIBFITH, BOBBBT BGLBSFIBLB, M. B. 

A Universal Formulary, containing the Methods of Preparing and Adminis- 
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- 
ists. Third edition, thoroughly revised, with numerous additions, by John M. Maisch, 
Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 
In one octavo volume of 775 pages, with 38 illustrations Cloth, $4.50: leather, $5.50. 



Lea Brothers & Co.'s Publications — Pathol., Histol. 



13 



Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School, London. . 

Pathology and Morbid Anatomy. New (sixth) American from the seventh' 
revised English edition. Octavo, 539 pp., with 167 engravings. Cloth, $2.75. Just ready. 



The Pathology and Morbid Anatomy of Dr. 
Green is too well known by members of the medi- 
cal profession to need any commendation. There 
is scarcely an intelligent physician anywhere who 
has not the work in his library, for it is almost an 
essential. In fact it is better adapted to the wants 
of general practitioners than any work of the kind 
witn which we are acquainted. The works of 
German authors upon pathology, which have been 



translated into English, are too abstruse for the 
physician. Dr. Green's work precisely meets his 
wishes. The cuts exhibit the appearances o f 
pathological structures just as they are seen 
through the microscope. The fact that it is so 
generally employed as a text-book by medical stu- 
dents is evidence that we have not spoken too 
much in its ia,y ox. —Cincinnati Medical News, Oct. 
1889. 



rAYNE, JOSEJPH F., M. D., F. B. C. JP., 

Senior Assistant Physician and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London^ 
A Manual of General Pathology. Designed as an Introduction to the Prac-- 
tice of Medicine. Octavo of 524 pages, with 152 illus. and a colored plate. Cloth, $3.50. , 
Knowing, as a teacher and examiner, the exact 1 cal factors in those diseases now with reasonable 
needs of medical students, the author has in the { certainty ascribed to pathogenetic microbes. In . 
work before us prepared for their especial use i this department he has been very full and explicit, 
what we do not hesitate to say is the best introduc- j not only in a descriptive manner, but in the tech- 
tion to general pathology that we have yet ex- | nique of investigation. The Appendix, giving 
amined. A departure which our author has j methods of research, is alone worth the price of the 
taken is the greater attention paid to the causa- I book, several times over, to every student of 
tionof disease, and more especially to theetiologi- 1 pathology. — St. Louis Med. and Surg. Jour., Jsi,n.^89. 

SFJS-JV, NICHOLAS, M.n., JPh.D., 

Professor of Principles of Surgery and Surgical Pathology in Push Medical College, Chicago. 
Surgical Bacteriology. In one handsome octavo of 259 pages, with 13 plates^ 
of which 9 are colored. Cloth, $1.75. 

COATS, JOSEBH, M. JD., F. F. F. S., 

Pathologist to the Glasgow Western Infirmary. 
A Treatise on Pathology. In one very handsome octavo volume of 829 pager 
with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. ' 



Medical students as well as physicians, who 
desire a work for study or reference, that treats 
the subjects in the various departments in a very 
thorough manner, but without prolixity, will cer- 
tainly give this one the preference to any with 
which we are acquainted. It sets forth the most 



manner, the changes from a normal condition 
effected in structures by disease, and points out 
the characteristics of various morbid agencies, 
so that they can be easily recognized. But, not 
limited to morbid anatomy, it explains fully how 
the functions of organs are disturbed by abnormal 



recent discoveries, exhibits, in an interesting j conditions.— (7i?ictn?Taci Medical News, Oct. 1883. 

WOOJDHFAn, G. SIMS, M. !>., F. M. C. F. F., 

Demonstrator of Pathology in the University of Edinburgh. 
Practical Pathology. A Manual for Students and Practitioners. In one beau 
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. 

It forms a real guide for the student and practi- 
tioner who is thoroughly in earnest in his en- 
deavor to see for himself and do for himself. To 
the laboratory student it will be a helpful com- 
panion, and all those who may wish to familiarize 



themselves with modern methods of examining 
morbid tissues are strongly urged to provide 



themselves with this manual. The numerous 
drawings are not fancied pictures, or merely 
schematic diagrams, but they represent faithfully 
the actual images seen under the microscope. 
The author merits all praise for having produced 
a valuable wor^.— Medical Record, May 31, 1884. 



SCHAFFn, FnWAMD A., F. B. S., 

Jodrell Professor of Physiology in University College, London, 

The Essentials of Histology. In one octavo volume of 246 pages, with 

281 illustrations. Cloth, $2.25. 

This admirable work was greatly needed. It cially adapted for laboratory work, at the same 

has been written with the object of supplying time it is intended to serve as an elementary 

the student with directions for the microscopical text-book of histology, comprising all the essen- 

examination of the tissues, which are given in a tial facts of the science.— TAe Physician and Sur- 

clear and understandable way. Although espe- geon, July, 1887. 

KLFIN, F., M. n., F. B. S., 

Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew'' s Hosp., London, 
Elements of Histology. Fourth edition. In one 12mo. volume of 376 pages, 

with 194 illus. Limp cloth, $1.75. See Students' Series of Manuals, page 31. 
Considered with regard to its contents, it can j index affords a ready reference to the histology ol 



only be looked on as a large and comprehensive 
volume. New and original illustrations have been 
added, with the help of which the structure of each 
tissue becomes clear to the reader. A copious 



every tissue and organ, and presents, at the same 
time, a complete glossary of the scientific terms.— 
Provincial Medical Journal, May 1, 1889. 



FFFFFB, A. J., M. B., M. S., F, B. C. S., 

Surgeon and Lecturer at St. Mary's Hospital, London. 
Surgical^ Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 31. 

Its form is practical, its language is clear, and in it nothing that is unnecessary. The list o 1 
the information set forth is well-arranged, well- subjects covers the whole range of surgery.— New 
indexed and well-illustrated. The student will find York Medical Journal, May 31, 1884. 



14 



Lea Brothers & Co.'s Publications— Practice of Med. 



:flint, AUSTiJsr, m. d., ll. d. 

Prof, of the Principles and Practice of Med. and of Clin. Mtd. in Bellewe Hospital Medical College^ N. Y. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly re- 
-vised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of 
Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., 
Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one Very handsome 
«3ctavo volume of 1160 pages, with illustrations. Cloth; $5.50 ; leather, $6.50. 



A new edition of a work of such established rep- 
^rtationas Flint's Medicine needs but few words to 
commend it to notice. It may in truth be said to 
■embody the fruit of his labors in clinical medicine, 
ripened by the experience of a long life devoted to 
its pursuit. America may well be proud of having 
produced a man whose indefatigable industry and 
gifts of genius have done so much to advance med- 
•1 cine; and all English-reading students must be 
grateful for the work which he nas left behind him. 
It has few equals, either in point of literary excel- 
leace, or of scientific learning, and no one can 
study its pages without being struck by the lu- 
cidity and accuracy which characterize them. It 
is qualities such as these which render it so valu- 
able for its purpose, and give it a foremost place 
among the text-books of this generation. — The 
London Lancet, March 12, 1887. 

f No text-book on the principles and practice of 
medicine has ever met in this country with such 



general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 
vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this vast country the book that will be most likely 
to be found in the office of a medical man, whether 
in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and as 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical Art— Cincinnati Medical Neivs, Oct. 1886. 



MABTSHOItWJE, ME WHY, M. I)., LL. I)., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
loyal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00. 



^ Within the compass ol 600 pages it treats of the 
history of medicine, general pathology^ general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
:3ip€utics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
-of its kind that we have seen. — Glasgow Medical 
..Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 
sa better average of actual practical treatment than 



this one; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow, 
but they are the most valuable in affording the 
means to see at a glance the whole literature of any 
disease, and the most valuable treatment. — Chicago 
Medical Journal and Examiner, April, 1882. 



MBYWOLnS, J. nUSSJELL, M. D., 

Professor of the Principles and Practice of Medicine in University College, London. 

A System of Medicine. With notes and additions by Henry Hartshorne, 
A- M., M. D., late Professor of Hygiene in the University of Pennsylvania. , In three large 
mad handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Eussia, raised bands, 
$6.50. Per set, cloth, $15; leather, $18. Sold only by subscription. 



Really too much praise can scarcely be given to 
this noble book. It is a cyclopsedia of medicine 
written by some of the best men of Europe. It is 
full of useful information, such as one finds fre- 
<q[uent need of in one's daily work. As a book 



of reference it is invaluable. It is up with the 
times. It is clear and concentrated in style, and 
its form is worthy of its famous publisher. — 
Louisville Medical News, Jan. 31, 1880. 



ElILLJE, ALFUBD, M. !>., LL. !>., 

Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna^ 
Cholera : Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- 
ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. 



WATSOJsr, sin thomas, m. n., 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 190 illustrations, by PIenry 
Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. 
fe two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00. 



JLECTURES ON THE STUDY OF FEVER. By 
A. HxTDSON, M. D., M. R. I. A. In one octavo 
volume of 308 pages. Cloth, S2.50. 

M. TREATISE ON FEVER. By Robeet D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25. 



BRISTOWE'S PRACTICE OF MEDICINE. In 
one octavo volume. 

LA ROCHE ON YELLOW FEVER, considered in 
its Historical, Pathological, Etiological and 
Therapeutical Relations. In two large and han.i- 
some octavo volumes of 1468 pp. Cloth, 87.00. 



Lea Brothers & Co.'s Publications — System of Med. 
For Sale hy Subscription Only* 



15 



A System of Practical Medicine. 

BY AMERICAN AUTHORS. 

Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICTNET AND OF 
ClilNICAL. MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, 

Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in tlwt 
Hospital of the University of Pennsylvania. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now readj^-^ 
Price per volume, cloth, $5; leather, $6 ; half Russia, raised bands and open back, |7. 



In this great work American medicine is for the first time reflected by its worthiest 
teachers, and presented in the full development of the practical utility which is its pre- 
eminent characteristic. The most able men — from the East and the West, from the- 
North and the South, from all the prominent centres of education, and from all the ■ 
hospitals which afford special opportunities for study and practice — have united J in 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that to each author has been 
assigned the subject which he is peculiarly fitted to discuss, and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with full certainty of finding what he needs 
in its most recent aspect, whether he seeks information on the general principles of medi- 
cine, or minute guidance in the treatment of special disease. So wide is the scope of the 
work that, with the exception of midwifery and matters strictly surgical, it embraces the 
whole domain of medicine, including the departments for which the physician is accustomed 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most' 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Medicine, and the general practitioner possessing it 
may feel secure that he will require little else in the daily round of professional duties. 

In spite of every effort to condense the vast amount of practical information fur- 
nished, it has been impossible to present it in less than 5 large octavo volumes, containing 
about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary 
octavos. Illustrations are introduced wherever requisite to elucidate the text. 

A detailed prospectus will be sent to any address on application to the publishers 



These two volumes bring this admirable work 
to a close, and fully sustain the high standard 
reached by the earlier volumes ; we have only 
therefore to echo the eulogium pronounced upon 
them. We would warmly congratulate the editor 
and his collaborators at the conclusion of their 
laborious task on the admirable manner in which, 
from first to last, they have performed their several 
duties. They have succeeded in producing a 
work which will long remain a standard work of 
reference, to which practitioners will look for 

faidance, and authors will resort for facts, 
rom a literary point of view, the work is without 
any serious blemish, and in respect of production, 
it has the beautiful finish that Americans always 
give their works. — Edinburgh Medical Journal, Jan. 
1887. 

* * The greatest distinctively American work on 
the practice of medicine, and, indeed, the super- 
lative adjective would not be inappropriate were 
even all other productions placed in comparison. 
An examination of the five volumes is sufficient 
to convince one of the magnitude of the enter- 

J)rise, and of the success which has attended its 
ulfilment.— T'/ie Medical Age, July 26, 1886. 

This huge volume forms a fitting close to the 
great system of medicine which in so short a time 
has won so high a place in medical literature, and 
has done such credit to the profession in this 
country. Among the twenty-three contributors 
are the names of the leading neurologists in 
America, and most of the work in the volume is of 
the highest order.— ^Boston Medical and Surgical 
Journal, July 21, 1887. 

We consider it one of the grandest works on 
Practical Medicine in the English language. It is 
a work of which the profession of this country can 
feel proud. Written exclusively by American 



physicians who are acquainted with all the varies 
ties of climate in the United States, the character 
of the soil, the manners and customs of the peo- 
ple, etc., it is peculiarly adapted to the wants 
of American practitioners of medicine, and it 
seems to us that every one of them would desire 
to have it. It has been truly called a " Complete 
Library of Practical Medicine," and the general 
practitioner will require little else in his round 
of professional duties.— Cincinnati Medical News^ 
March, 1886. 

Each of the volumes is provided with a roost 
copious index, and the work altogether promisea 
to be one which will add much to the medical 
literature of the present century, and reflect great 
credit upon the scholarship and practical acumen 
of its authors. — The London Lancet, Oct. 3, 1885. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, is fully justified by the character of the 
work. The entire caste of the system is in keep- 
ing with the best thoughts of the leaders and fol- 
lowers of our home school of medicine, and the 
combination of the scientific study of disease and 
the practical application of exact and experimcB- 
tal knowledge to the treatment of human mal- 
adies, makes every one of us share in the pride 
that has welcomed Dr. Pepper's labors. Sheared 
of the prolixity that wearies the readers of the. 
German school, the articles glean these same 
fields for all that is valuable. It is the outcome 
of American brains, and is marked throughout 
by much of the sturdy independence of thought 
and originality that is a national characteristic^ 
Yet nowhere is there lack of study of the most 
advanced views of the day. — North Carolina Medi" 
cal Journal, Sept. 1886. 



16 



Lea Brothers & Co.'s Publications — Clinical Med., etc. 



FOTSE^GILL, J. 31., M. D., Edin,, 31. B. C. P., Land., 

Physician to the City of London Hospital for Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. New (third) edition. In one 8vo. vol. of 661 pages. Cloth, $3.75; leather, $4.75. 

To have a description of the normal physiologi- 
cal processes of an organ and of the methods of 
treatment of its morbid conditions brought 
together in a single chapter, and the relations 
between the two clearly stated, cannot fail to prove 



a great convenience to many thoughtful but busy 
physicians. The practical value of the volume is 
greatly increased by the introduction of many 
prescriptions. That the profession appreciates 
that the author has undertaken an important work 
and has accomplished it is shown by the demand 
i'OT this third edition. — N. Y. Med. Jour., June 11,'87. 



This is a wonderful book. If there be such a 
thing as "medicine made easy," this is the work to 
accopaplish this result.— Va. Med. Month., June,'87. 

It is an excellent, practical work on therapeutics, 
well arranged and clearly expressed, useful to the 
student and young practitioner, perhaps even to 
the old.— Dublin Journal of Medical Science, March. 
1888. 

We do not know a more readable, practical and 
useful work on the treatment of disease than the 
one we have now before us.— Pacific Medical and 
Surgical Journal, October, 1887. 



VAUGIFAW, riCTOB C, Bh. D., M. !>., 

Prof, of Phys. and Path. Chem. and Assoc. Prof, of Therap. and Mat. Med. in the Univ. of Mich. 

and WOVY, FBBDEBICK G., 3£. D. 

Instructor in Hygiene and Phys. Chem. in the Univ. of Mich. 

Ptomaines and Leucomaines, or Putrefactive and Physiological 
Alkaloids. In one handsome 12mo. volume of 311 pages. Just ready. Cloth, $1.75. 

This book is what has been wanted for some [ observers and experimenters on micro-organisms, 
years by the medical profession. The subject of ' and to trace the relationship of cause and effect 
ptomaines and leucomaines, so far as their disease- ! of the putrefactive alkaloids. We congratulate 
producing relations are concerned, has been under | the authors upon the successful presentation ot 
special study scarcely more than a decade, but the current views on the subject in such manner 



within that period facts have been discovered 
upon which theories of permanent standing have 
been built, until now the practitioner is far be- 
hind the times if he does not appreciate the 
importance of ptomaines. This is the first attempt 
•made to collect into book form the results of 



as to make them easily comprehensible, while to 
the practitioner, after he has carefully read the 
book, it will serve, also, as a frequent reference 
work, because of the technical information it gives. 
Va. Medical Monthly, Sept. 1888. 



:FINLAYS0N, JA3IES, M. n., Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

Clinical Manual for the Study of Medical Cases. With Chapters 
by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of 
the Female Organs; Dr. Kobertson on Insanity; Dr. Gemmell on Physical Diagnosis; 
Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- 
taking, Family History and Symptoms of Disorder in the Various Systems. Kew edition. 
In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. 



The profession cannot but welcome the second 
^edition of this very valuable work of Finlayson 
^nd his collaborators. The size of the book has 
t>een increased and the number of illustrations 
nearly doubled. The manner in which the subject 
is treated is a most practical one. Symptoms 
alone and their diagnostic indications form the 
basis of discussion. The text explains clearly and 
fully the methods of examinations and the con- 
clusions to be drawn from the physical signs.— 
The Medical News, April 23, 1887. 

We are pleased to see a second edition of this 
admirable book. It is essentially a practical 



treatise on medical diagnosis, in which every sign 
and symptom of disease is carefully analyzed, and 
their relative significance in the different affec- 
tions in which they occur pointed out. From their 
synthesis the student can accurately determine 
the disease with which he has to deal. The book 
has no competitor, nor is it likely to have as long 
as future editions maintain its present standard of 
excellence. The general practitioner will find 
many practical hints in its pages, while a careful 
study of the work will save him from many pitfalls 
in diagnosis. — Liverpool Medico- Chirurgical Jour- 
nal, January, 1887. 



FENWICK, SA3rUEL, 31. I)., 

Assistant Physician to the London Hospital. 

The Student's Guide to Medical Diagnosis. From the third revised and 
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 
87 illustrations on wood. Cloth, $2.25. 

MABEBSSOJSr, S. O., 31. D., 

Senior Physician to and late Lect. on Principles and Practice of Med. at Chuy^s Hospital, London. 
On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, CEsophagus, Caecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one handsome octavo 
volume of 554 pages, with illustrations. Cloth, $3.50. 



This valuable treatise on diseases of the stomach 
and abdomen will be found a cyclopsedia of infor- 
mation, systematically arranged, on all diseases of 
the alimentary tract, from the mouth to the 
rectum. A fair proportion of each chapter is 
devoted to symptoms, pathology, and therapeutics. 
The present edition is fuller than former ones in 
many particulars, and has been thoroughly revised 
and amended by the author. Several new chap- 
ers have been added, bringing the work fully up 



to the times, and making it a volume of interest to 
the practitioner in every field of medicine and 
surgery. Perverted nutrition is in some form 
associated with all diseases we have to combat, 
and we need all the light that can be obtained on 
a subject so bread and general. Dr. Habershon's 
work is one that every practitioner should read 
and study for himself. — N. Y. Medical Journal, 
April, 1879. 



lAWJS^EB, TM031AS JELAWKES, 31. D. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
rom the second London edition. Kevised and enlarged by Tilbury Fox, M. D. 
In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 



Lea Brothers & Co.'s Publications — Hy^ene, Electr., Pract. 17 



BAnTELOLOW, BOBBB^TS, A. M., M, D., LL. ID., 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. 
Medical Electricity. A Practical Treatise on the Applications of Electricity 
to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 
308 pages, with 110 illustrations. Cloth, $2.50. 

The fact that this work has reached its third edi- [ should read it, especially when it is recalled what 
tion in six years, and that it has been kept fully i possibilities lie in the path of the further study of 
abreast with the increasing use and knowledge of I the therapeutics of electricity. Dr. Bartholow has 
electricit3',demonstrates its claim to be considered ; here presented the profession with a concise work 
a practical treatise of tried value to the profession, that, oeginning with elementary descriptions and 
The matter added to the present edition embraces : principles, gradually grows, page by page, into a 
the most recent advances in electrical treatment. 1 magnificently practical treatise, describing opera- 
The illustrations are abundant and clear, and the I tious in detail, and giving records of successes 
work constitutes a full, clear and concise manual that prove electricity to be marvellous as a curative 
well adapted to the needs of both student and ' agent in many forms of disease. The doctor can- 
practitioner.— TAe Medical xTew.«, May 14, 1887. [ not now do better than to possess himself of Dr. 

This "practical treatise on the applications of! Bartholow's treatise, just as it is. — Virginia Medir 
electricity to medicine and surgery" has grown to j cal 2Ionthly, June, 1887. 
be so important a work that every practitioner i 

YJEO, I. BUBNJEY, M. 1)., F. B. C. P., 

Professor of Clinical Therapeutics in King's College, London, and Physician to King's College 
Hospital. 

Pood in Health and Disease. In one 12mo. volume of 590 pages. Cloth, $2. 
Just ready. See Series of Clinical Manuals, page 31. 



Dr. Yeo is fully master of his subject and he 
supplies in a compact form nearh^ all that the 
practitioner requires to know on the subject of 
diet. The work is divided into two parts— food in 
health and food in disease. Dr. Yeo has gathered \ 
together from all quarters an immense amount of 
useful information within a comparatively small j 



compass, and he has arranged and digested his 
materials with skill for the use of the practitioner. 
We have seldom seen a book which more thor- 
oughly realizes the object for which it was written 
than this little work of Dr. Yeo.— British Medical 
Journal, Feb. 8, 1890. 



BICSABDSOJS^, B. W., M.D., LL. D., F.B.S., 

Fellow of the Royal College of Physicians, London. 
Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, $5. 



Dr. Richardson has succeeded in producing a 
work which is elevated in conception, comprehen- 
sive in scope, scientific in character, systematic in 
arrangement, and which is written in a clear, con- 
cise and pleasant manner. He evinces the happy 
faculty of extracting the pith of what is known on 
the subject, and of presenting it in a most simple, 
intelligent and practical form. There is perhaps 
no similar work written for the general public 
that contains such acomplete, reliable and instruc- 
tive collection of data upon the diseases common 
to the race, their origins, causes, and the measures 
for their prevention. The descriptions of diseases 
are clear, chaste and scholarly ; the discussion of 



the question of disease is comprehensive, masterly 
and fully abreast with the latest and best knowl- 
edge on the subject, and the preventive measures 
advised are accurate, explicit and reliable.— T/ie 
American Journal of the Medical Sciences, April, 1884. 

This is a book that will surely find a place on the 
table of every progressive physician. To the medi- 
cal profession, whose duty 'is quite as much to 
prevent as to cure disease, the book will be a boon. 
— Boston Medical and Surgical Journal, March 6, '84. 

The treatise contains a vast amount of solid, val- 
uable hygienic information.— J^edicai and Surgical 
Reporter, Feb. 23, 1884. 



THE TJEAB-BOOK OF TBEATMENT FOB 1890. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine. In one 12mo. volume of 329 pages. Cloth, $1.25. Just ready. 
.x.\ For special commutations with periodicals see page 2. 
In the present issue of the Year-Book of Treat- a large mass of information, valuable to the prac- 



ment we find the usual clear, concise, complete 
and accurate epitome of the chief advances made 
in the treatment of disease during the year end 
ing Sept. 1st. The different subjects are arranged 
in sections under the heads of the principal sys- 
tems of the body. The serial medical literature 
of England, Arcierica and of the Continent has 
been laid under contribution, with the result that 



titioner, is presented for his immediate reference. 
Brief notices of the most important new books on 
each subject add greatly to the value of the annual 
retrospect. Such a book, produced as it is in an 
elegant and convenient form and at a very low 
price, ought to be in the hands of every member 
of the profession. — The Practitioner, Feb. 1890. 



THE TEAB' BOOKS of TBEATMENT for 1886-87 -89. 

Similar to above. 12mo., 320-341 pages. Limp cloth, |1.25 each. 



SCHBEIBEB, JOSEFM, M. JD. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of 274 pages, with 117 fine engravings. Cloth, |2.75. 



STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, 81.25. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis, 
M. D. Edited by Frank H. Davis, M. D. Second 
edition. 12mo. 287 pages. Cloth, 81.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth, 82.50. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, 82.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condie, 
M. D. 1 vol. 8vo., pp. 603. Cloth, 82.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
some octavo volume of 302 pp. Cloth, 82.75. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 493. Cloth, 83.50. 



18 



Lea Brothers & Co.'s Publications — Throat, Lungs, Heart. 



Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y. 

A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis ot 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. New (fifth) edition. 
Edited by James C. Wilson, M. D., Jefferson Medical College, Philadelphia. In one 
handsome royal 12mo. volume of about 300 pages, with 14 illustrations. Preparing. 
A notice of the previous edition is appended. 

passed through four editions attests its popularity. 
There is a tendency among physical diagnosti- 
cians to make altogether too many varieties of 



The original work done by Dr. Flint in the devel- 
opment of the art of physical diagnosis will always 
make this manual an authority on this subject. 
Among all the works issued on this topic during 
the last few years, none exceeds this one in sim- 
plicity and completeness. The fact that it has 



morbid chest sounds, and especially of rales. The 
conciseness of Dr. Flint's Manual is one of its chief 
advantages —Medical Record, June 16, 1888. 



B 7 THE SAME A UTHOR. 



A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; In a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50. 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 



Essays on Conservative Medicine and Kindred Topics, 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 



In one very hand- 



BROWNB, LBNNOX, F. R. C. S., JE., 

Senior Physician to the Central London Throat and Ear Hospital. 

A Practical Guide to Diseases of the Throat and Nose, including 
Associated Affections of the Ear. With 120 illustrations in color, and 235 en- 
gravings on wood. New (third) and enlarged edition. In one imperial octavo volume 
of 714 pages. Cloth, $6.-50. Just ready. 



SBILBIt, CAUL, M. JD., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. New (third) edition. In one handsome royal 12mo. 
volume of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25. 



Few medical writers surpass this author in 
ability to make his meaning perfectly clear In a 
few words, and in discrimination in selection, both 



of topics and methods. The book deserves a large 
sale, especially among general practitioners— C/it- 
cago Medical Journal and Examiner, April, 1889. 



COHEN, J. SOLIS, M. !>., 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest m the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of Affections of the Pharynx, CEsophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 



GROSS, S. n., M.JD., LL.JD., n.C.L. Oxon., LL,JD. Cantab. 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 

octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 



BMOADBBWT, W, m, M. !>., F. M. C. JP., 

Physician to and Lecturer on Medicine at St. Mary''s Hospital, London. 
The Pulse. In one 12mo. volume of 312 pages. Cloth, $1.75. Just ready. See 
Series of Clinical Manuals, -page 31. 



FULLER ON DISEASES OF THE LQNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 



valence in various Countries. Second and revised 
edition. In one 12mo. vol., pp. 158. Cloth, $1.25. 

SMITH ON CONSUMPTION; its Early and Reme- 
diable Stages. 1 vol. 8vo., pp. 253. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.60 



Lea Brothers & Co.'s Publications — Nerv. and Ment. Dis., etc. 19 



one octavo 



nOSS, JAMBS, M.n., F.H. C.JP., LL.n., 

Seyiior Assistant Physician to the Manchester Royal Infirmary. 

A Handbook on Diseases of the Nervous System. In 

volume of 725 pages, with 184 illustrations. Cloth, |4.50 ; leather, $5.50. 

This admirable work is intended for students of 
medicine and for such medical men as have no time 
for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 
disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 



the department of medicine of which it treats. 
Dr. Ross holds such a high scientific nosition that 
any writings which bear his name are naturally 
expected to have the impress of a powertui intel- 
lect. In every part this handbook merits tne 
highest praise, and will no doubt be found ot the 
greatest value to the student as well as to the prac- 
titioner.— E'/in6urg/i Medica/ Journal, Jan. 1887. 



MITCHELL, S. WBin, M. D., 

Physician to Orthopcedic Hospital and the Infirinary for Diseases ot the Nervous System, Phila., etc. 

Lectures on Diseases of the ISTervous System; Especially in Women. 
Second edition. In one 12mo. volume of 288 pages. Cloth, $1.75. 

No work in our language develops or displays 
more features of that many-sided affection, hys- 



teria, or gives clearer directions for its differen- 
tiation, or sounder suggestions relative to its 
general management and treatment. The book 
IS particularly valuable in that it represents in 
the main the author's own clinical studies, which 
have been so extensive and fruitful as to give his 



teachings the stamp of authority all over the 
realm of medicine. The work, although written 
by a specialist, has no exclusive character, and 
the general practitioner above all others will find 
its perusal profitable, since it deals with diseases 
which he frequently encounters and must essay 
to ixeaX.— American Practitioner, August, 1885, 



SAMILTOW, ALLAN McLAWB, 31. 2>., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelVs Island, N. Y. 

Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 

revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. 

When the first edition of this good book appeared j characterized this book as the best of its kind in 

we gave it our emphatic endorsement, and the j any language, which is a handsome endorsement 



E resent edition enhances our appreciation of the 
ook and its author as a safe guide to students of 
clinical neurology. One of the best and most 
critical of English neurological journals. Brain, has 



from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old.- 
Alienist and Neurologist, April, 1882. 



TTJKE, nAWIBL HACK, M. D., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates 

It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomena the more firmly 



has ^e adhered to a physiological and rational 



Cloth, $3. 
method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing.— iVeio York Medical Journal, September 6, 1884. 



CLOUSTOW, THOMAS S., M. !>., F. B. C. F., L. B. C. S., 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 
Abstract of the Statutes of the United States and of the Several States and Territories re- 
lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor 
of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume of 541 
pages, with eight lithographic plates, four of which are beautifully colored. Cloth |4. 

The practitioner as well as the student will ac- 
cept the plain, practical teaching of the author as a 
forward step in the literature of insanity. It is 



refreshing to find a physician of Dr, Clouston's 
experience and high reputation giving the bed- 
side notes upon which nis experience has been 
founded and his mature judgment established. 
Such clinical observations cannot but be useful to 



the general practitioner in guiding him to a diag- 
nosis and indicating the treatment, especially in 
many obscure and doubtful cases of mental dis- 
ease. To the American reader Dr. Folsom's Ap- 
pendix adds greatly to the value of the work, and 
will m iiie it a desirable addition to every library. 
— American Psychological Jow^nal, July, 1884. 



g^*Dr. Folsom's Abstract may also be obtained separately in one octavo volume of 
108 pages. Cloth, $1.50. 

SAVAGE, GEOBGE H., M. !>., 

Lecturer on Mental Diseases at Ghiy^s Hospital, London. 

Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. 
of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, page 31. 

rLATFAIB, W. 



F. B. C. F. 



s., M. n.. 

The Systematic Treatment of Nerve Prostration and Hysteria. In 

one handsome small 12mo. volume of 97 pages. Cloth, $1.00. 

Blandford on Insanity and its Treatment: Lectures on the Treatment 

Medical and Legal, of Insane Patients. In one very handsome octavo volume. ' 

Jones' Clinical Observations on Functional Nervous Disorders. 

Second American Edition. In one handsome octavo volume of 340 pages. Cloth, $3.25* 



20 



Lea Brothers & Co.'s Publications — Surgery. 



ASMJajTBST, JOSW, Jr., M. D., 

Barton Prof, of Surgery and Clin. Surgery in Urdu, of Penna., Surgeon to the Penna. Hosp., etc. 

The Principles and Practice of Surgery. New (fifth) edition, enlarged 
and thoroughly revised. In one large and handsome octavo volume of 1144 pages with 
642 illustrations. Cloth, $6 ; leather, $7. Just ready. 

This is one of the most popular and useful ol 



A complete and most excellent work on surgery. 
It is only necessary to examine it to see at once 
its excellence and real merit either as text-book 
for the student or a guide for the general practi- 
tioner. It fully considers in detail every surgical 
injury and disease to which the body is liable, and 
every advance in surgery worth noting is to be 
found in its proper place. It is unquestionably the 
best and most complete single volume on surgery, 
in the English language, and cannot but receive 
that continued appreciation which its merits justly 
demand. — Southern Practitioner, Feb. 1890. 



the many well-known treatises on general surgery. 
It furnishes in a concise manner a clear and 
comprehensive description of the modes of prac- 
tice now generally employed in the treatment of 
surgical affections, with a plain exposition of the 
principles on which those modes of practice are 
based. The entire work has been carefully revised, 
and a number of new illustrations introduced 
that greatly enhance the value of the book.— 
Cincinnati Lancet-Clinic, Dec. 14, 1889. 



JDBTIITT, MOBJEBT, M. B. C. S., etc. 

Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- 
ley Boyd, M. B., B. S., F. K. C. S. In one 8vo. volume of 965 pages, with 373 illustra- 
tions. Cloth, $4 ; leather, $5. 



It is essentially a new book, rewritten from be- 
ginning to end. The editor has brought his work 
up to the latest date, and nearly every subject on 
which the student and practitioner would desire 
to consult a surgical volume, has found its place 
here. The volume closes with about twenty pages 
of formulse covering a broad range of practical 
therapeutics. The student will find that the new 
Druitt is to this generation what the old one was 
to the former, and no higher praise need be 
accorded to any volume.— iVorf A Carolina Medical 
Journal, October, 1887. 



Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text-book to a very large extent. Dur- 
ing the late war in this country it was so highly 
appreciated that a copy was issued by the Govern- 
ment to each surgeon. The present edition, while 
it has the same features peculiar to the work at 
first, embodies all recent discoveries in surgery, 
and is fully up to the times. Cincinnati Medical 
News, September, 1887. 



GANT, FJREJDJEBICK JAMES, F. JR. C. S., 

Senior Surgeon to the Royal Free Hospital. 
The Student's Surgery. A Multum in Parvo. In one square octavo volume 
of 848 pages, with 159 engravings. Cloth, $3.75. 

The claims of this volume to be a multum in 
parvo are certainlj' substantiated. The author 
covers the whole field of clinical and operative 



surgery in about eight hundred pages of very co: 
pactly printed matter. For a student's manual it 
appears to us in every way excellent, containing 
almost everything necessary to equip the student 
with sound, matter-of-fact knowledge on surgical 



subjects. The volume is a condensation of the 
autnor's well-known larger works on surgery, 
notably his " Science and Practice of Surgery ". 
Students requiring the essentials of surgery 
in a handy and condensed form, and those who 
cannot devote time to theoretical or speculative 
pathology will find this volume exceedingly ser- 
viceable^— r^P%sician and Surgeon, April, 1890 



BOBBBTS, J. B., M. D., 

Professor of Anatomy and Surgery in the Philadelphia Polyclinic. Professor of the Principles and 
Practice of Surgery in the Womari's Medical College of Pennsylvania. 

The Principles and Practice of Modern Surgery. For the use of Students 
and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 
850 pages, with about 425 illustrations. In press. 

In this volume, as its title indicates, the author has endeavored to give a thorough 
exposition of the best surgical practice of the present time. Not relying on his own 
large experience, he has consulted the latest literature of all kinds bearing on his spec- 
ialty, and has gleaned therefrom the opinions of the best authorities, and the methods of 
the most practical surgeons. The well-established facts of the science are clearly stated, 
but history, theories and untried ianovations are rigidly excluded. The work is richly 
illustrated. In the selection of matter and in the consideration of the vast number of 
questions involved, the author has used his most critical judgment ia the endeavor to 
render the work of the greatest practical advantage to both practitioners and students. 

GBOSS, S. n., M. n., LL. J>., n. C. L. Oxon., LL. n. 
Cantab., 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15. 

BALL, CMABLLJS B., M. Ch., L>ub., F. B. C. S., E., 

Surgeon and Teacher at Sir P. Dunn's Hospital, Dublin. 

Diseases of the Rectum and Anus. In one 12mo. volume of 417 pages, 
with 54 engravings and 4 colored plates. Cloth, $2.25. Just ready. See Series of Clinical 
Manuals, page 31. 

GIBWEY, V. F., H. n.. 

Surgeon to the Orthopaedic Hospital, New York, etc. 
Orthopsedie Surgery. For the use of Practitioners and Students, 
some octavo volume, profusely illustrated. Preparing. 



In one hand- 



Lea Brothers & Co.'s Publications — Surg-ery. 



21 



JEBICSSEN, JOJELN JE., F. JR. S., F. B. C. S., 

Professor of Surgery in University College, London, etc. 
The Science and Art of Surgery; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. From the eighth and enlarged English edition. In two large and 



beautiful octavo volumes of 2316 
Cloth, $9 ; leather, raised bands, $11. 

We have always regarded "The Science and 
Art of Surgery" as one of the best surgical text- 
books in the English language, and this eighth 
edition only confirms our previous opinion. We 
take great pleasure in cordially commending it to 
our re&ders.— The Medical News, April 11, 1885. 

For many years this classic work has been 
made by preference of teachers the principal 
text-book on surgery for medical students, while 
through translations into the leading continental 
languages it may be said to guide the surgical 
teachings of the civilized world. No excellence 
of the former edition has been, dropped and no 
discovery, device or improvement which has 



pages, illustrated with 984 engravings on wood. 



marked the progress of surgery during the last 
decade has been omitted. The illustrations are 
many and executed in the highest style of art. 
—Louisville Medical News, Feb. 14, 1885. 

We cannot speak too highly of this excellent 
work. It represents the most advanced and settled 
views in regard to the science of surgery, and will 
ever be found a faithful guide and counsellor in 
practice. — Canada Lancet, Maj% 1885. 

It appears simultaneously in England, America, 
Spain and Italy, and is too well known as a safe 
guide and familiar friend to need further com- 
ment. — New York Medical Journal, March 28, 1885. 



BBYAJ^T, TSOMAS, F. JB. C. S., 

Surgeon and Lecturer on Surgery at Ouy^s Hospital, London. 
The Practice of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 
727 illustrations. Cloth, $6.50; leather, $7.50. 



The fourth edition of this work is fully abreast 
of the times. The author handles his subjects 
with that degree of judgment and skill which is 
attained by years of patient toil and Varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 
place tne work among the highest order of text- 
books for the medical student. Almost every 
topic in surgery is presented in such a form as to 



enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost witn useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical. — Chicago Medical Journal and Examiner, 
April, 1886. 

This book is essentially what it purports to be, 
viz.: a manual for the practice of surgery. It is 
peculiarly well fitted for the student or busy general 
practitioner. — The Medical News, August 15, 1885. 



TBFVBS, FBFDFBICK, F. B. C. S., 

Hunterian Professor at the Royal College of Surgeons of England. 
A Manual of Surgery. In Treatises by Various Authors. In three 12mo. 
volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See 
Students^ Series of Manuals, page 31. 



We have here the opinions of thirty-three 
authors, in an encyclopsedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 



the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance.— Cin- 
cinnati Lancet-Clinic, August 21, 1886. 



MABSJBL, SOWABD, F. H. C. S., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. 
Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts 
ai;d a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 31. 

BTITLIW, SEWHY T., F. It. C. S., 

Assistant Surgeon to St. Bartholomew'' s Hospital, London. 
Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored 
plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 31. 

The language of the text is clear and concise, veniently scattered through general works on sur- 
The author has aimed to state facts rather than to gery and the practice of medicine. The physician 
express opinions, and has compressed within the and surgeon will appreciate its value as an aid and 
compass of this small volume tne pathology, etiol- guide.— Physician and Surgeon, Sept. 1886. 
ogy, etc., of diseases of the tongue that are incon- 



TBFVJES, FBEDEBICK, F. M. C. S., 

Surgeon to and Lecturer on Surgery at the London Hospital. 

Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 
illustrations. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 31. 

justice to the author in a few paragrap 
tinal Obstruction is a work that will p: 
equal value to the practitioner, the student, the 



A standard work on a subject that has not been 
so comprehensively treated by any contemporary 
English writer. Its completeness renders a full 
review difficult, since every chapter deserves mi- 
nute attention, and it is impossible to do thorough 



Intes- 
will prove of 



pathologist, the physician and the operating' sur- 
geon. — British Medical Journal, Jan. 31, 1885. 



GOUZn, A. FFABCF, M. S., M. B., F. B. C. S., 

Assistant Surgeon to Middlesex Hospital. 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 
pages. Cloth, $2.00. See Students^ Series of Manuals, page 31. 

PIRRIE'S PRINCIPLES AND PRACTICE OF one 8vo. vol. of 638 pages, with 340 illustrations. 

SURGERY. Edited by John Neill, M. D. In Cloth, $3.75. 

one8vo.vol. of784pp.with316illus. Cloth, $3.75. MILLER'S PRACTICE OF SURGERY. Fourth 

MILLER'S PRINCIPLES OF SURGERY. Fourth and revised American edition. In one large 8yo. 

American from the third Edinburgh edition. In vol. of 682 pp., with 364 illustrations. Cloth, $3.76. 



22 Lea Brothers & Co.'s Publications— Surgery, Frac, I>isloc. 



SMITH, 8TBPMBN, M. n., 

Professor of CllaicoJ Surgery in the University of the City of Nexo York. 

The Principles and Practice of Operative Surgery. New (second) and 
thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 
1005 illustrations. Cloth, |4 00; leather, |5.00. 



This excellent and very valuable book is one of 
the most satisfactory works on modern operative 
surgery yet published. Its author and publisher 
have spared no pains to make it as far as possible 
an ideal, and their efforts have given it a position 
prominent among the recent works in this depart- 
ment of surgery. The book is a compendium for 
the modern surgeon. The present, the only revised 
edition since 1879, presents many changes from 
the original manual. The volume is much en- 
larged, and the text has been thoroughly revised, 
so as to give the most improved methods in asep- 



tic surgery, and the latest instruments known for 
operative work. It can be truly said that as a hand- 
book for the student, a companion for the surgeon, 
and even as a book of reference for the physician 
not especially engaged in the practice of surgery, 
this volume will long hold a most conspicuous 
place, and seldom will its readers, no matter how- 
unusual the subject, consult its pages in vain. Its 
compact form, excellent print, numerous illustra- 
tions, and especially its decidedly practical char- 
acter, all combine to commend \t.~Boston Medical 
and Surgical Journal, May 10, 1888. 



SOLMBS, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A Treatise on Surgery ; Its Principles and Practice. New American 
from the fifth English .edition, edited by T. Pickering Pick, F. E. C. S., Surgeon and 
Lecturer on Surgery at St. George's Hospital, London. In one octavo volume of 997 
pages, wiih 428 illustrations. Cloth, $6; leather, $7. Just ready. 

for the general practitioner, teaching those things 
that are necessary to be known for ttie successful 
pro ecution of the physician's career, imparting 
nothing that in our present knowledge is consid- 
ered unsafe, unscientific or inexpedient.— Paci^c 
Medical Journal, July, 1889. 



To the younger members of the profession and 
to others not acquainted with the book and its 
merits, we take pleasure in recommending it as a 
surgery complete, thorough, well- written, fully 
illustrated, modern, a work sufficiently volumi- 
nous for the surgeon specialist, adequately concise 



JTOLMJES, TIMOTBLY, M, A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery ;, Theoretical and Practical. IN TREATISES BY 
VARIOUS AUTHORS. American edition, thoroughly revised and re-edited 
by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. 
In three large imperial octavo volumes containing 3137 double- coiumned pages, with 
979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per 
set, cloth, $18.00 ; leather, $21.00. Sold only by subscription. 

STIMSOJ^, LBWIS A., B. A., M. T>., 

Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Surgery in the Medical 
Faculty of Univ. of City of N. Y., Corresponding Member of the Societe de Chirurgie of Paris. 
A Manual of Operative Surgery. New (second) edition. In one very hand- 
some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50 
There is always room for a good book, so that 

while many works on operative surgery must be 

considered superfluous, that of Dr. Stimson has 

held its own. The author knows the difficult art 

of condensation. Thus the manual serves as a 

work of reference, and at the same time as a 

handy guide. It teaches what it professes, the 

steps of operations. In this edition Dr. Stimson 

has sought to indicate the changes that have been 



effected in operative methods and procedures by 
the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of imi- 
tation.— J5riitis^ Medical Journal, Jan. 22, 1887. 



By the same Author. 
A Treatise on Fractures and Dislocations. 



In two handsome octavo vol- 



umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Disloca- 
tions, 540 pages, with 163 illustrations. Complete work, cloth, $5.50; leather, $7.50. 
Either volume separately, cloth, $3.00; leather, $4.00. 



The appearance of the second volume marks the 
completion of the author's original plan of prepar- 
ing a work which should present in the fullest 
manner all that is known on the cognate subjects 
of Fractures and Dislocations. The volume on 
Fractures assumed at once the position of authority 
on the subject, and its companion on Dislocations 
will no doubt be similarly received. The closing 
volume of Dr. Stimson's work exhibits the surgery 



of Dislocations as it is taught and practised by the 
most eminent surgeons of the present time. Con- 
taining the results of such extended researches it 
must for a long time be regarded as an authority 
on all subjects pertaining to dislocations. Every 
practitioner of surgery will feel it incumbent on 
him to have it for constant reference. — Cincinnati 
Medical News, May, 1888. 



HAMILTON, FBAWK H., M. D., LL. jD., 

Surgeon to Bellevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations. Seventh edition 
thoroughly revised and much improved. In one very handsome octavo volume of 998 
pages, with 379 illustrations. Cloth, $5.50 : leather, $6^0 
This book is without a rival in any language. 



_ _ It 

is essentially a practical treatise, and it gathers 
within its covers almost everything valuable that 
has been written about fractures and dislocations. 
The principles and methods of treatment are very 



fully given. The book is so well known that it does 
not require any lengthened review. We can only 
say that it is still unapproached as a treatise.— 
The Dublin Journal of Medical Science, Feb. 1886. 



BICK, T. BICKBBIJSra, F. B. C. S., 

Surgeon to and Lecturer on Surgery at St. George's Hospital, London. 

Fractures and Dislocations. In one 12mo. volume of 530 pages, 
illustrations. Limp cloth, $2.00. See Series of Clinical Manuals, page 31. 



with 93 



Lea Brothers & Co.'s Publications — Otol., Oplithal. 23 

BVBNBTT, CHARLES M,, A. M., M, I)., 

Professor of Otology in the Philadelphia Polyclinic ; President of the American Otological Society. 

The Ear, Its Anatomyj Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. Second edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, |5.00. 

We note with pleasure the appearance of a second { carried out, and much new matter added. Dr. 
edition of this valuable work. When it first came : Burnett's work must be regarded as a very valua- 
out it was accepted by the profession as one of i ble contribution to aural surgery, not only on 
the standard works on modern aural surgery in ! account of its comprehensiveness, but because it 



the English language; and in his second edition 
Dr. Burnett has fully maintained his reputation, 
for the book is replete with valuable information 
and suggestions. The revision has been carefully 



contains the results of the careful personal observa- 
tion and experience of this eminent aural surgeon. 
—London Lancet, Feb. 21, 1885. 



rOLITZJEn, AJDAM, 

Imperial^Royal Prof, of Aural Therap. in the Univ. of Vienna. 
A Text-Book of the Ear and its Diseases. Translated, at the Author's re- 
quest, by James Patterson Cassells, M. D., M. E. C. S. In one handsome octavo vol- 
ume of 800 pages, with 257 original illustrations. Cloth, $5.50. 

The whole work can be recommended as a reli- I the practitioner in his treatment. — Boston Medical 
able guide to the student, and an efficient aid to | and Surgical Journal, June 7, 1883. 



BJEMMT, GEOBGE A., M. B., E. B. C. S., Ed., 

Ophthalmic Surgeon, Edinburgh Royal Infirmary. 
Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. In 
one octavo volume of 683 pages, with 144 illustrations, 62 of which are beautifully 
colored. Cloth, $7.50. 

This newest candidate for favor among ophthal- | novice — with a mass of details with no key to their 
mological students is designed to be purely clinical ! unravelling. It is apparent that the literature of 
in character and the plan is well adhered to. We | each subject has been gone over in a very thor- 
have been forcibly struck by the rare good taste j ough manner. The fact that he was writing a 
in the selection of what is essential which per- ; clinica) treatise for beginners and not an encyclo- 
vades the book. The author seems to have the | psedia has always been present with the author, 
uncommon faculty of viewing his subject as a j The number and excellence of the colored illus- 
whole and seizing the salient points and not con- trations in the text deserve more than a passing 
fusing his reader — presumably a student and a [ notice. — Archives of Ophthalmology, S^.-pt. 1889. 



JUZEB, JEEENBY E., F. B. C. S., 

Senior Ass^t Surgeon, Royal Westminster Ophthalmic Hosp. ; late Clinical Ass't, Moorfields, London. 

A Handbook of Ophthalmic Science and Practice. Handsome 870. vol- 
ume of 460 pages, with 125 woodcuts, 27 colored plates, selections from Test-types of 
Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50 ; leather, $5.50. 

It presents to the student concise descriptions | illustrations are nearly all original. We have ex- 
and typical illustrations of all important eye affec- i amined this entire work with great care, and it 
tions, placed in juxtaposition, so as to be grasped i represents the commonly accepted views of ad- 
at a glance Beyond a doubt it is the best illus- vanced ophthalmologists. We can most heartily 
trated handbook of ophthalmic science which has commend this book to all medical students, prac- 
ever appeared. Then, what is still better, these 1 titioners and specialists.— Z)etroii Lancet, Jan. '85. 



NETTLESELIB, EJDWABD, E. B. C. S., 

Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' Hospital, London. 

The Student's Guide to Diseases of the Eye. New (third) edition, thor- 
oughly revised. With a chapter on the Detection of Color-Blindness, by William 
Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. In one 
12mo. volume of 479 pages, with 164 illust., test-types and formulae. Cloth, $2. 

The extent of the sale of this now accepted 1 in the chapter devoted to operations. A very 
authority has conclusively shown that its claim for ! important partof the work to general practitioners 
favor was not an imaginary one. The introductory I is that embraced in the consideration of eye dis- 
chapter on optical outlinesis a wonderfully clear ! eases in relation to general diseases and condi- 
statement of the principles involved. The writer's | tions. The arrangement of the remedies employed 
decision of character has fully impressed his pro- j into a formulary is adopted, and it contains much 
duction, and this is nowhere'more apparent than | useful knowledge. — South. Practitioner, Dec. 1887. 



]!fOBBIS, W3I. F., M. D., and OLIVEB, CJSAS. A., M. D. 

Clin. Prof, of Ophthalmology in Univ. of Pa. 
A Text-Book of Ophthalmology. In one octavo volume of about 500 pages, 
with illustrations. Preparing. 

CABTEB, B. BBTinEJS^ELL, & EBOST, W. ADAMS, 

E. B. C. S., F. B. a S., 

Ophthalmic Surgeon to and Lect. on Ophthal- Ass't Ophthalmic Surgeon and Joint Led. 

mic Surgery at St. George's Hospital, London. on Oph. Sur., St. George's Hosp., London. 

Ophthalmic Surgery. In one 12mo.. volume of 559 pages, with 91 woodcuts, 
color blindness test, test-types and dots and appendix of formulae. Cloth, $2.25. See 
Series of Clinical Manuals, page 31. 

WELLS ON THE EYE. In one octavo volume, i laWSON ON INJURIES TO THE EYE, ORBIT 
LAURENCE AND MOON'S HANDY BOOK OF ^ND EYELIDS: Their Immediate and Remote 
OPHTHALMIC SUKv^LRl , for the use of Prac- 1 Effects. In one octavo volume of 404 pages, with 
titioners. Second edition. In one octavo vol- 92 illustrations. Cloth, S3.50, 
ume of 227 pages, with 65 lUus. Cloth, $2.75. 1 ' "* 



24 Lea Brothers & Co.'s Publications — Urin. Dls., Dentistry, etc. 



BOBJEMTS, WILLIAM, M. D., 

Lecturer on Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Benal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In one hand- 
some octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 

It maybe said to be the best book in print on the [ guage in its account of the different affections.— 
subject of which it treats. — The American Journal The Manchester Medical Chronicle, July, 1885. 



of the Medical Sciences, Jan. 1886 

The peculiar value and finish of the book are in 
a measure derived from its resolute maintenance 
of a clinical and practical character. It is an un- 
rivalled exposition of everything which relates 
directly or indirectly to the diagnosis, prognosis 
and treatment of urinary diseases, and possesses 
a completeness not found elsewhere in our lan- 



The value of this treatise as a guide book to the 
physician in daily practice can hardly be over- 
estimated. • That it is fully up to the level of our 
present knowledge is a fact reflecting great credit 
upon Dr. Roberts, who has a wide reputation as a 
busy practitioner. — The Medical Record, July 31, 



rVMDY, CSABLES W., M. />., Chicago. 

Bright's Disease and Allied Affections of the Kidneys. 

volume of 288 pages, with illustrations. Cloth, $2 

The object of this work is to "furnish a system- 
atic, practical and concise description of the 
pathology and treatment of the chief organic 
diseases of the kidney associated with albuminu- 
ria, which shall represent the most recent ad- 
vances in our knowledge on these subjects ; " and 
this definition of the object is a fair description of 
the book. The work is a useful one, giving in a 



In one octavo 



short space the theories, facts and treatments, and 
going more fully into their later developments. 
On treatment the writer is particularly strong, 
steering clear of generalities, and seldom omit- 
ting, what text-books usually do, the unimportant 
items which are all important to the general prac- 
titioner. — The Manchester Medical Chronicle, Oct. 



mohbis, jebkby, m. b., f. b. a s., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. 

Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 
woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 31. 

he took in hand, 
book of reference 



In this manual we have a distinct addition to 
surgical literature, which gives information not 
elsewhere to be met with in a single work. Such 
a book was distinctly required, and Mr. Morris 
has very diligently and ably performed the task 



It is a full and trustworthy 
both for students and prac- 
titioners in search of guidance. The illustrations 
in the text and the ehromo-lithographs are beau- 
tifully executed. — The London Lancet,Feb. 26, 1886. 



LUCAS, CLJEMBKT, M. B., B. S., I\ M. C.S., 

Senior Assistant Surgeon to Ghuy's Hospital, London. 

Diseases of the Urethra. In one 12mo. volume. 
of Clinical Manuals, page 4. 



Preparing. See Series 



TSOMI'SOJSl, SIB SJEJSBY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulse. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

THE AMJEBICAW SYSTEM OF DENTISTBY. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1863 illustrations and 9 full page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. The complete work is now ready. For sale by 
subscription only. 



As an encyclopaedia of Dentistry it has no su- 

f)erior. It should form a part of every dentist's 
ibrary, as the information it contains is of the 
greatest value to all engaged in the practice of 
dentistry. — American Jour. Dent. Sci., Sept. 1886. 

A grand system, big enough and good enough 
and handsome enough for a monument (which 



doubtless it is), to mark an epoch in the history of 
dentistry. Dentists will be satisfied with it and 
proud of it — they must. It is sure to be precisely 
what the student needs to put him aJid keep him 
in the right track, while tne profession at large 
will receive incalculable benefit from it. — Odonto- 
graphic Journal, Jan. 1887. 



COLFMAJ^, A., L. B. C. J*., F. B. C. S., Exam. L. D. S., 

Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., 
D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25 



It should be in the possession of every practi- 
tioner in this country. The part devoted to first 
and second dentition and irregularities in the per- 
manent teeth is fully worth the price. In fact, 
price should not be considered in purchasing sueh 
a work. If the money put into some of our so- 
called standard text-books could be converted into 
such publications as this, much good would result. 
— Southern Dental Journal, May, 1882. 



The author brings to his task a large experience 
acquired under the most favorable circumstances. 
There have been added to the volume a hundred 
pages by the American editor, embodying the 
views of the leading home teachers in dental sur- 
gery. The work, therefore, may be regarded as 
strictly abreast of the times, and as a very high 
authority on the subjects of which it treats. — 
American Practitioner, July, 1882. 



BASHAM ON RENAL DISEASES: A Clinical 
Guide to their Diagnosis and Treatment. In 



one 12mo. vol. of 304 pages, with 21 illustraticns. 
Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Venereal, Impotence. 25 

GHOSS, SAMUBL W., A. M., M. D., LL. D., 

Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. New (4th) edition, thoroughly revised by F. E. 
Stuegis, M. D., Prof, of Diseases of the Genito-Urinary Organs and of Venereal Diseases, 
N. Y. Post Grad. Med. School. In one very handsome octavo volume of about 175 
pages, with about 20 illustrations. Preparing. 

A few notices of the previous edition are appended. 
It must be gratifying to both author and pub- 1 This now classical work on the subject of impo- 
lishers that large first and second editions of this tence and sterility in the male needs no extended 
little work were so soon exhausted, while the fact j review, for it is already well known to the pro- 
that it has been translated into Kussian may indi- ! fession. Dr. Gross has by his tireless labor done 
cate that it filled a void even in foreign literature, j more towards clearing up the diagnosis and treat- 
His is a careful and physiological study of the i mentof these obscure cases than any other Ameri- 
sexual act, so far as concerns the male, and all ! can physician. The fact that this book has rapidly 
his conclusions are scientifically reached. The i run through two large editions, and that the author 
book has a place by itself in our literature, and ! is now forced to issue a third, is good and sufficient 
famishes a large fund of information concerning ; evidence of its excellence. — Atlanta Medical and 
important matters that are too often passed over Surgical Journal, April, 1888. 
in silence. — The Medical Press, June, 1887. | 



TATLOB, B. W., A. M., M. JD., 



Surgeon to Charity Hospital, New York, Prof, of Venereal and Skin Diseases in the University of 
Vermont, Pres. of the Am. Dermatological Ass^n. 

The Pathology and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. Being the sixth edition of Bumstead 
and Taylor. Entirely rev^ritten by Dr. Taylor. Large 8vo. volume, about 900 pages, 
with about 150 engravings, as well as numerous chromo-lithographs. Preparing. 
A few notices of the previous edition are appended. 

It is a splendid record of honest labor, wide I known that it would be superfluous here to pass in 
research, just comparison, careful scrutiny and i review its general or special points of excellence, 
original experience, which will always be held as The verdict of the profession has been passed; it 
a high credit to American medical literature. This | has been accepted as the most thorough and corn- 
is not only the best work in the English language j plete exposition of the pathology and treatment of 
upon the subjects of which it treats, but also one I venereal diseases in the language. Admirable as a 
wnich has no equal in other tongues for its clear, j model of clear description, an exponent of sound 
comprehensive and practical handling of its j pathological doctrine, and a guide for rational and 
themes. — Am. Jour, of the Med. Sciences, Jan, 1884. \ successful treatment, it is an ornament to the medi- 

It is certainly the best single treatise on vene- j cal literature of this country. The additions made 
real in our own, and probably the best in any Ian- i to the present edition are eminently judicious, 
guage. — Boston Med. and Surg. Journal, April 3, 1884. | from the standpoint of practical utility.— Journal of 

The character of this standard work is so well i Cutaneous, and Venereal Diseases, Jan. 1884. 



COBJSriL, v., 

Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. Simes, 
M. D., Demonstrator of Pathological Histology in the Univ. of Pa., and J. William 
White, M. D., Lecturer on Venereal Diseases, Univ. of Pa. In one handsome octavo 
volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. 

The anatomy, the histology, the pathology and | perusal without the feeling that his grasp of the 
the clinical features of syphilis are represented in j wide and important subject on which it treats is 
this work in their best, most practical and most | a stronger and surer one. — The London Practi- 
instructive form, and no one will rise from its \ tioner, Jan. 1882. 

SUTCSIJSrSOW, JONATJSAK, F. M. S., F. B. C. S., 

Consulting Surgeon to the London Hospital, 
Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. Cloth, 
$2.25. See Series of Olinical Manuals, •p2ige SI . 

Those who have seen most of the disease and j and power of observation, but of his patience and 
those who have felt the real difficulties of diagno- : assiduity in taking notes of his cases and keep- 
sis and treatment will most highly appreciate the j ing them in a form available for such excellent 
facts and suggestions which abound in these j use as he has put them to in this volume.— London 
pages. It is a worthy and valuable record, not | Medical Record, Nov. 12, 1887. 
only of Mr. Hutchinson's very large experience j 



GMOSS, S. n., M. JD., XL. JD., JD. C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
edition, thoroughly revised by Samuel W. Gross, M. D. In one octavo volume of 574 
pages, with 170 illustrations. Cloth, $4.50. 

CVLLBBIBB, A., & BUJKSTJEAJD, F. J., JK.JD., LJL.JD., 

Surgeon to the Hopital du Midi. Late Professor of Venereal Diseases in the College of Physicians 

and Surgeons, New York. 

An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- 
stead, M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, 
containing about 150 figures, beautifully colored, many of them the size of life. Strongly 
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS FORMS OF LOCAL DISEASE AFFECTING 
DISORDERS. In one 8vo vol. of 479 p. Cloth, S3.25. PRINCIPALLY THE ORGANS OF GENERA- 
LEE'S LECTURES ON SYPHILIS AND SOME i TION. In one 8vo. vol. of 246' pages. Cloth, $2.25. 



26 



Lea Brothers & Co.'s Publications — Venereal, Skin. 



TAYLOB, ROBERT W., A.M., M.D., 

Surgeon to Gharity Hospital, New York, and to the Department of Venereal and Skin Diseases of 
the New York Hospital. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis, 
Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and 
comprising 58 beautifully-colored plates with 213 figures, and 431 pages of text with 85 
engravings. Complete work just ready. Price per part, $2.50. Bound in one volume, 
half Russia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen 
plates sent on receipt of 10 cents. A full prospectus sent to any address on application. 

allotted to a notice of this kind, and while we 



The completion of this raonumental work is a 
subject of congratulation, not only to the author 
and publishers, but to the profession at large ; 
indeed it is to tne latter that it directly appeals as 
a wonderfully clear exposition of a confessedly 
difficult branch of medicine Good literature has 
joined hands with good art with highly satisfac- 
tory results for both. There are altogether 213 
figures, many of which are life size, and represent 
the highest perfection of the chromo-litho- 
graphic art, and scattered throughout the text are 
innumerable engravings. Quite a proportion of 
these illustrations are from the author's own 
collection, while on the other hand the best 
atlases of the world have bpen drawn upon for 
the most typical and successful pictures of the 
many different types of venereal and skin dis 
ease. We think we may say without undue 
exaggeration that the reproductions, both in color 
and in black and white, are almost invariably 
successful. The text is practical, full of thera- 
peutical suggestions, and the clinical accounts of 
disease are clear and incisive. Dr. Taylor is, 
happily, an eminent authority in both departments, 
and we find as a consequence that the two divis- 
ions of this work possess an equal scientific and 
literary merit. We have already passed the limits 



have nothing but praise for this admirable atlas, 
it must be said in justification that it is more than 
warranted by the merits of the work itself. — 
The Medical News, Dec. 14, 1889. 

It would be hard to use words which would per- 
spicuously enough convey to the reader the great 
value of this Clinical Atlaa. This Atlas is more 
complete even than an ordinary course of clinical 
lectures, for in no one college or hospital course 
is it at all probable that all of the diseases herein 
represented would be seen. It is also more ser- 
viceable to the majority of students than attend- 
ance upon clinical lectures, for most of the 
students who sit on remote seals in the lecture 
hall cannot see the subject as well as the office 
student can examine these true to-life chromo-lith- 
ographs. Comparing the text to a lecturer, it is 
more satisfactory in exa<-tness and fulness than 
he would be likely to be in lecturing over a single 
case. Indeed, this Atlas is invaluable to the gen- 
eral practitioner, for it enables the eye of the 
physician to make diagnosis of a given case of 
skin manifestation by comparing the case with 
the picture in the Atlas, where will be found also 
the text of diagnosis, pathology, and full sections 
on treatment.— Virginia Medical Monthly,Dec., 1889. 



SYDB, J. WBVIWS, A. M., M. !>., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. New (second) edition. In one handsome octavo volume of 676 pages, 
with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50; leather, $5.50. 

The second edition of his treatise is like his 



We can heartily commend it, not only as an 
admirable text-book for teacher and student, but 
in its clear and comprehensive rules for diagnosis, 
its sound and independent doctrines in pathology, 
and its minute and judicious directions for the 
treatment of disease, as a most satisfactory and 
completepractical guide for the physi(;ian.— J. weri- 
can Journal of the Medical Sciences, July, 1888. 

A useful glossary descriptive of terms is given. 
The descriptive portions of this work are plain 
and easily understood, and above all are very 
accurate. The therapeutical part is abundantly 
supplied with e,xcellent recommendations. The 
picture part is well done. The value of the work 
to practitioners is great because of the excellence 
of the descriptions, the suggestiveness of the 
advice, and the correctness of the details and the 
principles of therapeutics impressed upon the 
reader. — Virginia Med. Monthly, May, 1888. 



clinical instruction, admirably arranged, attractive 
in diction, and strikingly practical throughout. 
The chapter on general symptomatology is a model 
in its way ; no clearer description of the various 
primary and consecutive lesions of the skin is to 
be met with anywhere. Those on general diagno- 
sis and therapeutics are also worthy of careful 
study. Dr. Hyde has shown himself a compre- 
hensive reader of the latest literature, and has in- 
corporated into his book all the best of that which 
the past years have brought forth. The prescrip- 
tions and formulae are given in both common and 
metric systems. Text and illustrations are good, 
and colored plates of rare cases lend additional 
attractions. Altogether it is a work exactly fitted 
to the needs of a general practitioner, and no one 
will make a mistake in purchasing it. — Medical 
Press of Western New York, June, 1888. 



FOX, T., M. n., F.B. C. JP., and FOX, T. €., B.A., M.B. C.S., 

Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the 

University College Hospital, London. Westminster Hospital, London. 

An Epitome of Skin Diseases. With Formulae. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume 
of 238 pages. Cloth, $1 .25. 



The third edition of this convenient handbook 
calls for notice owing to the revision and expansion 
which it has undergone. The arrangement of skin 
diseases in alphabetical order, which is the method 
of classification adopted in this work, becomes a 
positive advantage to the student. The book is 
one which we can strongly recommend, not only 
to students but also to practitioners who require a 
compendious summary of the present state of 
dermatology.— ^-/-itisA Medical Journal, July 2, 1883. 

We cordially recommend Fox's Epitome to those 
whose time is limited and who wish a handy 



manual to lie upon the table for instant reference. 
Its alphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The present edition has been very carefully 
revised and a number of new diseases are de- 
scribed, while most of the recent additions to 
dermal therapeutics find mention, and the formu- 
lary at the end of the book has been considerably 
augmented.— r/ie Medical News, December, 1883. 



WILSOJV, FBASMUS, F. B. S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 

In one handsome small octavo volume of 535 pages. Cloth, $3.50. 

flILLIER'S HANDBOOK OF SKIN DISEASES; I can edition. In one 12mo. volume of 353 pages, 
for Students and Practitioners. Second Ameri- | with plates. Cloth, $2.25. 



Lea Brothers & Co.'s Publications — I>is. of "Women. 



27 



The American Systems of Gynecology and*Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A.M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings and 8 plates. Complete work just ready. Per vol- 
ume: Cloth, $5.0C; leather, $6.00; half Eussia, $7.00. For sale by subscription only. 
Address the Publishers. Full descriptive circular free on application. 

LIST OF CONTRIBUTORS. 

Dm 



WILLIAM H. BAKER, M 
ROBERT BATTEY, M. D., 
SAMUEL C. BUSEY, M. D., 
JAMES C. CAMERON, M. D., 
HENRY C. COE, A. M., M. D., 
EDWARD P. DAVIS, M. D., 
G E. De SCHAVEINITZ, M. D., 
E. r. DUDLEY, A. B., M. D., 
B. McE. EMMET, M. D., 
GEORGE J. ENGELMANN, M. D., 
HENRY J. GARRIGUES, A. M., M. D., 
WILLIAM GOODELL, A. M., M. D., 
EGBERT H. GRANDIN, A. M., M. D., 
SAMUEL W. GROSS, M. D., 
ROBERT P. HARRIS, M. D., 
GEORGE T. HARRISON, M. D., 
BARTON C. HIRST, M. D. 
STEPHEN Y. HOWELL, M. D., 
A. REEVES JACKSON, A. M., M. D., 
W. W. JAGGARD, M. D., 
EDWARD W. JENKS, M. D., LL. D., 
HOWARD A. KELLY, M. D., 
This is volume two of The American System of 
Obstetrics, completing the wonderfully full series 
issued from the house of Lea Broiliers & Co. dur- 
ing the past two years. Two magnificent volumes 
devoted to gynecology, and now two like volumes 
embracing everj'thing pertaining to obstetrics. 
These volumes are the contributions of the most 
eminent gentlemen of this country in these de- 
partments of the profession. Each contributor 
presents a monograph upon his special topic, 
apparently without restriction in space, so that 
everything in the way of history, theory, methods, 
and results is presented to our fullest need. The 
work will long remain as a monument of great in- 
dustry and good judgment. As a work of general 
reference, it will be found remarkably full and in- 
structive in every direction of inquiry.— T/?e Ob- 
stetric Gazette, September, 1889. 

There can be but little doubt that this work will 
find the same favor with the profession that has 
been accorded to the "System of Medicine by 
American Authors," and the "System of Gynecol- 
ogy byAmeriean Authors." One is at a loss to know 
what to say of this volume, for fear that just and 
merited praise may be mistaken for flattery. The 
subjects of some of the papers are discussed in 
various works on obstetrics, though not to the full 
extent that is found in this volume. The papers 
ol Drs. Engelmann, Martin, Hirst, Jaggard and 
Reeve are incomparably beyond anything that can 
be found in obstetrical works. Certainly the Edi- 



D.. 



LL. D. 
D., 
M. D., 



CHARLES CARROLL LEE, M. D., 
WILLIAM T. LUSK, M. D.,LL. D., 
J. HENDRIE LLOYD, M. D , 
MATTHEW D. MANN, A. M., M. D., 
H. NEWELL MARTIN, F. R. S., M. 

D.Sc, M.A., 
RICHARD B. MAURY, M. D., 
C. D. PALMER, M. D., 
ROSWELL PARK, M. D., 
THEOPHILUS PARVIN, M. D. 
R. A. F. PENROSE, M. D., LL. 
THADDEUS A. REAMY, A. M., 
J. C. REEVE, M. D., 
A. D. ROCKWELL, A. M., M. D., 
ALEXANDER J. C. SKENE, M. D., 
J. LEWIS SMITH, M. D., 
STEPHEN SMITH, M. D., 
R. STANSBURY SUTTON, A. M., M. D ., 

LL. D., 
T. GAILLARD THOMAS, M. D., LL. D., 
ELY VAN DE WARKER, M. D., 
W. GILL WYLIE, xM. D. 
tor may be congratulated for having made such a 
wise selection of his contributors.— Journal of the 
American Medical Association, Stpt. 8, 1888. 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement: — "It is a work of which the pro- 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 
United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
"System of Gynecology by American Authors," 
which we desire now to bring to the attention of 
our readers. It, like the other, has been written 
exclusively by American physicians who are 
acquainted with all the characteristics of American 
people, who are well informed in regard to the 
peculiarities of American women, their manners, 
customs, modes of living, etc. As every practis- 
ing physician is called upon to treat diseases of 
females, and as they constitute a class to which 
the family physician must give attention, and 
cannot pass over to a specialist, we do not know of 
a work in any department of medicine that we 
should so strongly recommend medical men gen- 
erally purchasing.— Cmcinna/i Med. News, July,1887. 



TSOMAS, T. GAIZLAMD, M. J)., LL. n., 

Professor of Diseases of Women m the College of Physicians and Surgeons, N. Y. 

A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly 
revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 
illustrations. Cloth, $5.00 ; leather, $6.00. 



That the previous editions of the treatise of Dr. 
Thomas were thought worthy of translation into 
German, French, Italian and Spanish, is enough 
to give it the stamp of genuine merit. At home it 
has made its way into the library of every obste- 



trician and gynaecologist as a safe guide to practice. 
No small number of additions have been made to 
the present edition to make it correspond to re- 
cent improvements in treatment.— Pact/if Medical 
and Surgical Journal, Jan. 1881. 



Ems, AUTHUM W., M. D., Lond., JF.B. C.JP., M.B. C.S., 

Assist. Obstetric Physi cian to Middlesex Hospital, late Physician to British Lying-in Hospital. 
The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome 
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 



It is a pleasure to read a book so thoroughly 
good as this one. The special qualities which are 
conspicuous are thoroughness in covering the 
whole ground, clearness of description and con- 
ciseness of statement. Another marked feature of 
the book is the attention paid to the details of 
many minor surgical operations and procedures, 
as, for instance, the use of tents, application of 
leeches, and use of hot water injections. These | 



are among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete resume of the whole subject. Specialists, too, 
will find many useful hints in its pages. — Boston 
Med. and Surg. Journ., March 2, 1882. 



28 



Lea Brothers & Co.'s Publications — Dis. of Women, Midw^. 



EMMJET, THOMAS ADDIS, M. jD., LL. D., 

Surgeon to the Woman^s Hospital, New York, etc. 

The Principles and Practice of GynsBCOlogy ; For the use of Students and 
Practitioners of Medicine. Ncav (third) edition, thoroughly revised. In one large and very 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5 ; leather, |6 ; 
very handsome half Kussia, raised bands, $6.50. 
We are in doubt whether to congratulate the | the privilege thus offered them of perusing the 



author more than the profession upon the appear- 
ance of the third edition of this well-known work 
Embodying, as it does, the life-long experience of 
one who has conspicuously distinguished himself 
as a bold and successful operator, and who has 
devoted so much attention to the specialty, we 
feel sure the profession will not fail to appreciate 



views and practice of the author. His earnestness 
of purpose and conscientiousness are manifest. 
He gives not only his individual experience but 
endeavors to represent the actual state of gynse- 
cological science and art. — British Medical Jour- 
nal, May 16, 1885. 



TAIT, LA WSOJSr, F. B. C. S., 

Professor of Oyncecology in Queen's College, Birmingham; late President of the British Gryne^ 
cological Society; Fellow American Gynecological Society. 

Diseases of Women and Abdominal Surgery. 

octavo volumes. Volume I., 554 pages, 62 engravings and 3 
ready. Volume II., preparing. 



In two very handsome 
plates. Cloth, $3. Just 



The plan of the work does not indicate the regu- 
lar system of a text book, and yet nearly every- 
thing of disease pertaining to the various organs 
receives a fair consideration. The description of 
diseased conditions is exceedingly clear, and the 
treatment, medical or surgical, is very satisfactory. 



Much of the text is abundantly illustrated with 
cases, which add value in showing the results of 
the suggested plans of treatment. We feel con- 
fident that few gynecologists of the country will 
fall to place the work in their libraries.— T/ie 
Obstetric Gazette, March, 1890. 



DAVJEWFORT, F. H,, M. D., 

Assistant in Gyncecology in the Medical Department of Harvard University, Boston. 

Diseases of Women, a Manual of Non-Surgical Gyngecology. De- 
signed especially for the Use of Students and General Practitioners. In one handsome 
12mo. volume of 317 pages, with 105 illustrations. Cloth, $1.50. Just ready. 



We agree with the many reviewers whose no- 
tices we have read in other journals congratulating 
Dr. Davenport on the success which he has 
attained. He has tried to write a book for the 
student and general practitioner which would 
tell them just what they ought to know without 
distracting their attention with a lot of compila- 
tions for which they could have no possible use. 
In this he has been eminently successful. There 
is not even a paragraph of useless matter. 



Everything is of the newest, freshest and most 
practical, so much so that we have recommended 
it to our class of gynecology students. What the 
author advises in the way of treatment has all 
been practically tested by himself, and each 
method receives only so much commendation as he 
has found that it deserves. We are sure that 
these good qualities will command for it a large 
sale. — Canada Medical Record, Dec. 1889. 



MAY, CHAULES M., M. D., 

Late House Surgeon to Mount Sinai Hospital, New York. 
A Manual oftheDiseases of Women. Being a concise and systematic expo- 
sition of the theory and practice of gynecology. New (2d) edition, edited by L. S. Eau, 
M. D., Attending Gynecologist at the Harlem' Hospital, N. Y. In one 12mo. volume of 
360 pagep, with 31 illustrations. Cloth, $1.75. Just ready. 



This is a manual of gynecology in a very con- 
densed form, and the fact that a second edition 
has been called for indicates that it has met with 
a favorable reception. It is intended, the author 
tells us, to aid the student who after having care- 
fully perused larger works desires to review the 
subject, and he adds that it may be useful to the 
practitioner who wishes to refresh his memory 



rapidly but has not the time to consult larger 
works. We are much struck with the readiness 
and coavenience with which one can refer to any 
subject contained in this volume. Carefully com- 
piled indexes and ample illustrations also enrich 
the work. This manual will be found to fulfil its 
purposes very satisfactorily. — The Physician and 
Surgeon, June, 1890. 



DVJS^CAJSr, J. MATTHEWS, M.D., LL. !>,, F. H. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

They are in every way worthy of their author ; rule, adequately handled in the text-books ; others 
indeed, we look upon them as among the most of them, while bearing upon topics that are usually 
valuable of his contributions. They are all upon treated of at length in such works, yet bear such a 
matters of great interest to the general practitioner, stamp of individuality that they deserve to be 
Some of them deal with subjects that are not, as a widely read.— i\^. F. Medical Journal, March, 1880. 



HODGE ON DISEA.SES PECULIAR TO WOMEN. 
Including Dispiacementsof the Uterus." Second 
edition, revised and enlarged. In one beauti- 
fully printed octavo volume of 519 pages, with 
original illustrations. Cloth, $LbQ. 

RAMSBOTHAM-S PRINCIPLES AND PRAC- 
TICE OP OBSTETRIC MEDICINE AND 
SURGERY. In reference to the Process of 
Parturition. A new and enlarged edition, thor- 
oughly revised by the Author. With additions 
by W. V. Keat.ng, M. D , Professor of Obstetrics, 



etc., in the Jefferson Medical College of Phila- 
delphia. In one large and handsome imperial 
octavo volume of 640 pages, with 64 full page 
plates and 43 woodcuts in the text, containing in 
all nearly 200 beautiful figures. Strongly bound 
in leather, with raised bands, $7. 
WEST'S LECTURES ON THE DISEASES OF 
WOMEN Third American from the third Lon- 
don edition. In one octavo volume of 543 
Cloth, S3.75; leather, $4.75. 



Lea Brothers & Co.'s Publications — Midwifery. 



29 



:platfaib, w. s., m. n., f. h. a p., 

Professor of Obstetric Medicine in King's College, London, etc. 

A Treatise on the Science and Practice of Midwifery. New (fiftli) 
American, from the seventh English edition. Edited, with additions, by Robert P. Har- 
ris, M, D. In one handsome octavo volume of 664 pages, with 207 engravings and 5 
plates. Cloth, $4.00 ; leather, $5.00. Just ready. 



Playfair's Midwifery has for many years been a 
favorite authority both among obstetric teachers 
and general practitioners of the obstetric art. A 
work of this kind having reached a fifth American 
from the seventh English edition would seem 
scarcely to require any extended notice. Of 

fyrevious American editions the matter has been 
argely rewritten or remodelle-i, besides many 
new short notes have been added. For either the 
student or the old practitioner this work meets 
all needs; it is full and yet condensed ; it is clear 
and well arranged.— 06si!e^/^ic Gazette, Nov., 1889. 

Truly a wonderful book ; an epitome of all ob- 
stetrical knowledge, full, clear and concise. In 
thirteen years it has reached seven editions. It 



is perhaps the most popular work of its kind ever 
presented to the profession. Beginning with the 
anatomy and physiology of the organs concerned, 
nothing is left unwritten that the practical ac- 
coucheur should know. It seems that every 
conceivable physiological or pathological condi- 
tion from the moment of conception to the time 
of complete involution has had the author's 
patient attention. The plates and illustrations, 
carefully studied, will teach the science of mid- 
wifery. The reader of this book will have before 
him the very latest and best of obstetric practice, 
and also of all the coincident troubles connected 
therewith.— -Sou^/iern Practitioner, Dec, 1889. 



KIJ^G, A. F. A., M. JD., 

Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer- 
sity, Washington, D. C., and in the University of Vermont, etc. 

A Manual of Obstetrics. New (fourth) edition. In one very handsome 12mo. 
volume of 432 pages, with 140 illustrations. Cloth, $2.50. Just ready. 



Dr. King, in the preface to the first edition of 
this manual, modestly states that "its purpose is 
to furnish a good groundwork to the student at 
the beginning of his obstetric studies." Its pur- 
pose is attained ; it will furnish a good ground- 
work to the student who carefully reads it: and 
further, the busy practitioner should not scorn the 
volume because written for students, as it con- 
tains much valu*ble obstetric knowledge, some 



the description of labor, both normal and abnor- 
mal, that Dr. King is at his best. Here his style 
is so concise, and the illustrations are so good, 
that the veriest tyro could not fail to receive a clear 
conception of labor, its complications and treat- 
ment. Of the 141 illustrations it may be safely 
said that they all illustrate, and that the engraver's 
work is excellent. The name of the publishers 
is a sufficient guarantee that the work is pro- 
of which is not found in more elaborate text- j sented in an attractive form, and from every 
books. The chapters on the anatomy of the ; standpoint we can most heartily recommend the 
female generative organs, menstruation,"^fecunda- j book both to practitioner and student. — The Medi' 
tion, the signs of pregnancy, and the diseases of | cal News, Dec. 7, 1889. 
pregnancy, are all excellent and clear ; but it is in ! 



BABNES, BOBFBT, M. D., and lAWCOVBT, 31. JO., 

Phys. to the General Lying-in Hosp., Lond. Obstetric Phys. to St. Thomas' Hosp., Lond. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology by Prof. Milnes 
Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5 ; leather, $6. 

The immediate purpose of the work is to furnish 
a handbook of obstetric medicine and surgery 
for the use of the student and practitioner. It is 
not an exaggeration to say of the book that it is 
the best treatise in the English language yet 
published, and this will not be a surprise to those 
who are acquainted with the work of the elder 
Barnes. Every practitioner who desires to have 



the best obstetrical opinions of the time in a 
readily accessible and condensed form, ought to 
own a copy of the book. — Journal of the American 
Medical Association, June 12, 1886. 

The Authors have made a text-book which is in 
every way quite worthy to take a place beside the 
best treatises of the period. — New York Medical 
Journal, July 2, 1887. 



BABVIN, TSEOrSILVS, M. D., LL. JD., 

Prof, of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila. 
The Science and Art of Obstetrics. New (2d) edition. In one handsome 
8vo. volume of about 700 pages, with ab'out225 engravings and a colored plate. Shortly. 



BABKJEB, FOnnYCE, A. M., M. D., LL. D. FcUn., 

Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College, 
New York, Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc. 

Obstetrical and Clinical Essays. 12mo., about 300 pages. Preparing. 

:pabby, jomn s., m. n., 

Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. 

Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and 
Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. 



WUSrCKFL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed, 

For Students and Practitioners. Translated, with the consent of the Author, from the 
second German edition, by J. R. Chadwick, M. D. Octavo 484 pages. Cloth, $4.00. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 
American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth, 83.50. 

TANNER ON PREGNANCY. Octavo, 490 
colored plates. 16 cuts. Cloth, 84.25. 



CHURCHILL ON THE PUERPERAL FEVER 
AND OTHER DISEASES PECULIAR TO WO- 
MEN. In one 8vo. vol. of 464 pages. Cloth, 82.50. 

MEIGS ON THE NATURE, SIGNS AND TREAT- 
MENT OF CHILDBED FEVER. In one 8vo. 
volume of 346 pages. Cloth, $2.00. 



30 



Lea Brothers & Co.'s Publications — Midwfy., Dis. CMldn. 



LJEISMMAN, WILLIAM, M. D., 

Regius Professor of Midwifery in the University of Glasgow, etc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Third American edition, revised by the Author, with additions by 
John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and 
very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, |4.50 ; leather, 
$5.50. 



The author is broad in his teachings, and dis- 
cusses briefly the comparative anatomy of the pel- 
vis and the mobility of the pelvic articulations. 
The second chapter is devoted especially to 
the study of the pelvis, while in the third the 
female organs of generation are introduced. 
The structure and development of the ovum are 
admirably described. Then follow chapters upon 
the various subjects embraced in the study of mid- 
wifery. The descriptions throughout the work are 
plain and pleasing. It is sufficient to state that in 
this, the last edition of this well-known work, every 
recent advancement in this field has been brought 
forward.— P%sidan and Surgeon, Jan. 1880. 

To the American student the work before us 



must prove admirably adapted. Complete in all its 
parts, essentially modern m its teachings, and with 
demonstrations noted for clearness and precision, 
it will gain in favor and be recognized as a work 
of standard merit. The work cannot fail to be 
popular and is cordially recommended.— i\r. O. 
Med. and Surg. Journ., March. 1880. 

It has been well and carefully written. The 
views of the author are broad and liberal, and in- 
dicate a well-balanced judgment and matured 
mind. We observe no spirit of dogmatism, but 
the earnest teaching of the thoughtful observer 
and lover of true science. Take the volume as a 
whole, and it has few equ.a,\s.— Maryland Medical 
Journal, Feb. 1880. 



LAJf^niS, MEKBT G., A. M., M. D., 

Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O. 

The Management of Labor, and of the Lying-in Period. In 

handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. 



one 



The author has designed to place in the hands 
of the young practitioner a book in which he can 
find necessary information in an instant. As far 
as we can see, nothing is omitted. The advice is 
sound, and the proceedures are safe and practical. 
Centralb/att filr Gynakologie, December 4, 1886. 

This is a book we can heartily recommend, 
the author goes much more practically into the 
details of the management of labor than most 
text-books, and is so readable throughout as to 



tempt any one who should happen to commence 
the book to read it through. The author pre- 
supposes a theoretical knowledge of obstetrics, 
and has consistently excluded from this little 
work everything that is not of practical use in the 
lying-in room. We think that if it is as widely 
read as it deserves, it will do much to improve 
obstetric practice in general. — New Orleans Medi- 
cal and Surgical Journal, Mar. 1886. 



SMITH, J, LBWIS, M. D., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. 

A Treatise on the Diseases of Infancy and Childhood. New (sixth) 
edition, thoroughly revised and rewritten. In one handsome octavo volume of 867 
pages, with 40 illustrations. Cloth, $4.50 ; leather, $5.50. 

For years it has stood high in the confidence of 
the profession, and with the additions and alter- 
ations now made it may be said to be the best 
book in the language on the subject of which it 



treats. An examination of the' text fully sus- 
tains the claims made in the preface, that "in 
preparing the sixth edition the author has revised 
the text to such an extent that a considerable 
part of the book may be considered new." If the 
voung practitioner proposes to place in his library 
but one book on the diseases of children, we 
would unhesitatingly say, let that book be the one 
which is the subject of this notiae.— The American 
Journal of the Medical Sciences, April, 1886. 

No better work on children's diseases could be 
placed in the hands of the student, containing, as 
it does, a very complete account of the symptoms 
and pathology of the diseases of early life, and 
possessing the further advantage, in which it 
stands alone amongst other works on its subject, 
of recommending treatment in accordance with 
the most recent therapeutical yie\^s.— British and 
Foreign Medico-Chirurgical Review. 

Those familiar with former editions of the work 



will readily recognize the painstaking with which 
this revision has been made. Many of the articles 
have been entirely rewritten. The whole work m 
enriched with a research and reasoning which 
plainly show that the author has spared neither 
time nor labor in bringing it to its present ap- 
proach towards perfection. The extended table of 
contents and the well-prepared index will enable 
the busy practitioner to reach readily and quickly 
for reference the various subjects treated of in the 
body of the work, and even those who are familiar 
with former editions will find the improvements 
in the present richly worth the cost of the work. — 
Atlanta Medical and Surgical Journal, Dec. 1886. 

Dr. Smith's work hasjustly become the standard 
all over the world as the book on children's dis- 
eases The whole book is admirable, both for the 
practitioner and the student. Dr. Smith writes 
from a large experience and a close observation 
of cases at the bedside. He is extremely prac- 
tical, and these facts make the work what it is — 
the best of all works on the diseases of children. 
— Virginia Medical Monthly, June, 1886. 



OWJEN, EDMZfJSrn, M. B., F. B. C. S., 

Surgeon to the Children's Hospital, Great Ormond St., London. 

Surgical Diseases of Children. 

chromo-lithographic plates and 85 woodcuts 
page 31. 

One is immediately struck on reading this book 
with its agreeable style and the evidence it every- 
where presents of the practical familiarity of its 
author with his subject. The book may be 



In one 12mo. volume of 525 pages, with 4 
Cloth, $2. See Series of Clinical Manuals^ 

honestly recommended to both students and 
practitioners. It is full of sound information, 
pleasantly given.— .4 nnais of Surgery, May, 1886. 



WEST, CMABLBS, M. D., 

Physician to the Hospital for Sick Children, London, etc.. 

On Some Disorders of the Nervous System in Childhood. In one small 

12mo. volume of 127 pages. Cloth, $1.00. 



CONDIE'S PRACTICAL TREATISE ON THE 
DISEASES OF CHILDREN. Sixth edition, re- 



vised and augmented. In one octavo volume of 
779 pages. Cloth, $5.25 ; leather, $6.25. 



Lea Brothers & Co.'s Publications — Med. Juris., Miscel. 31 

TinY, CSAJILBS MJEYMOTT, M. B., F. C. S., 

Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital^ etc. 

Legal Medicine. VoiiUME II. Legitimacy and Paternity, Pregnancy, Abor- 
tion, Pape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, 
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- 
tavo volume of 529 pages. Cloth, $6.00 ; leather, $7.00. 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth, $6.00 ; leather, $7.00. 

The satisfaction expressed with the first portion tables of cases appended to each division of the 
of this work is in no wise lessened by a perusal of subject must have cost the author a prodigious 
the second volume. We find it characterized by amount of labor and research, but they constitute 
the same fulness of detail and clearness of ex- one of the most valuable features of the book, 
pression which we had occasion so highly to com- especially for reference in medico-legal trials. — 
mend in our former notice, and which render it so American Journal of the Medical Sciences, April, 1884. 
valuable to the medical jurist. The copious 



Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. 

Poisons in Relation to Medical Jurisprudence and Medicine. Third 

American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

By the Same Author. 
A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- 
don edition, thoroughly revised and rewritten. Edited by John J. Reese, M. D. In one 
large octavo volume. 

JPFFFFB, AUGUSTUS J., M. S., M. B., F. B. C. S., 

Examiner in Forensic Medicine at the University of London. 
Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Student^ 
Se7'ies of Manuals, below. 

STUnBNTS' SFBIFS OF MAJSUALS. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, 
written by eminent Teachers or Examiners, and issued in pocket-size 12mo volumes of 300-540 pages, 
richly illustrated and at a low price. The following volumeg are now ready: Treves' Manual of Sur' 
gery, by various writers, in ihree volumes, each, $2; Bell's Comparative Physio ogy and Anatomv, $2; 
Gould's Surgical Diagnosis. $2; Robertson's Physiological Physics, $2; Bruce's Materia Medicaand Thera- 
peutics (4th edition), $1.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's 
Dissectors' Manual, $1.50; Ralfe's Clinical Chemistry, $1.50; Treves' Surgical Applied Anatomy, $2; 
Pepper's Surgiml Pathology, $2 ; and Klein's Elements of Histology (4th edition), $1.75. The following 
is in press : Pepper's Forensic Medicine. For separate notices see index on last page. 



SFBIFS OF CLINICAL MANUALS. 

In arranging for this Series it has been the design of the publishers to provide the profession with 
a collection of authoritative monographs on important clinical subjects in a cheap and portable form. 
The volumes will contain about 550 pages and will be freely illustrated by chromo-lithographs and wood- 
cuts. The following volumes are now ready: Yeo on Food in Health and Disease, $2; Beoadbent on 
the Pulse,$l.15; Carter & Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, $2.25; Ball oa 
the Eectum and Anus, $2.25; Maesh on the Joints, $2; Owen on Surgical Diseases of Children, $2; 
Morris on Surgical Diseases of the Kidney, $2.25 ; Pick on Fractures and Dislocations, $2 ; Butlin on 
the Tongue, $3.50 ; Tr^yes on Intestinal Obstruction, $2; and Say a.ge on Insanity and Allied Neuroses, $2. 
The following is in active preparation: Lucas on Diseases of the Urethra. For separate notices see 
index on last page. 

LFA, MFNBY C. 

Chapters from the Religious History of Spain.— Censorship of th© 
Press. — Mystics and lUuminati.— The Endemoniadas of Queretaro. — 
El Santo Nino de la Guardia. — Brianda de Bardaxi. In one 12mo. volume 
of about 500 pages. In press. 

In making researches for a History of the Spanish Inquisition the author has been 
led to investigate various subjects deserving of treatment more elaborate than could be 
accorded to them in a continuous narrative. These he has worked out in the present vol- 
ume in the hope that beside the intrinsic interest of the themes themselves, they may 
serve to explain some of the causes which reduced to impotence a nation that in the 
sixteenth century aspired to universal monarchy. 

By the same Author. 
Superstition and Force : Essays on The Wager of Law, The Wager of 
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one 
handsome royal 12mo. volume of 552 pages. Cloth, $2.50. 

By the Same Author. 
Studies in Church History. The Rise of the Temporal Power— Ben- 
efit of Clergy — Excommunication. New edition. In one very handsome royal 
octavo volume of 605 pages. Cloth, $2.50. 



Allen's Anatomy . . . . .6 

American Journal of the Medical Sciences . 3 
American Systems of Gynecology and Obstetrics 27 
American System of Practical Medicine . .15 

American System of Dentistry - . .24 

A shhurst's Surgery ..... 20 
Ashwell on Diseases of "Women ... 29 
Attfield's Chemistry .... 9 

Ball on the Rectum and Anus . . . 20, 31 

Barker's Obstetrical and Clinical JEssays, . 29 

Barlow's Practice of Medicine . . . 17 

Barnes' System of Obstetric Medicine . . 29 

Bartholow on Electricity .... 17 
Basham on Renal Diseases .... 24 
Bell's Comparative Physiology and Anatomy . 7, 31 
Bellamy's Surgical Anatomy ... 6 

Berry on the Eye 23 

Billings' National Medical Dictionary . . 4 

Blandford on Insanity . . . .19 

Bloxam's Chemistry ..... 9 
Bristowe's Practice of Medicine ... 14 
Broadbent on the Pulse . . . . 18, 31 

Browne on the Throat, Nose and Ear . . 18 

Bruce's Materia Medica and Therapeutics . 12 
Brunton's Materia Medica and Therapeutics . 11 
Bryant's Practice of Surgery . . . .21 

Bumstead and Taylor on Venereal. See Taylor. 25 
Burnett on the Ear . . . . .23 

Butlin on the Tongue 21,31 

Carpenter on the Use and Abuse of Alcohol . 8 
Carpenter's Human Physiology ... 8 
Carter <fe Frost's Ophthalmic Surgery . .23,31 

Chambers on Diet and Regimen . . . 17 

Chapman's Human Physiology ... 8 
Charles' Physiological and Pathological Chem. 10 
Churchill on Puerperal Fever . . . 29 

Clarke and Lockwood's Dissectors' Manual . 6, 31 
Classen's Quantitative Analysis ... 10 
Cleland's Dissector . .... 6 

Clouston on Insanity . .... 19 

Clowes' Practical Chemistry ... 10 

Coats' Pathology . . , . .13 

Cohen on the Throat . . . . .18 

Coleman's Dental Surgery .... 24 
Condie on Diseases of Children . . .30 

Cornil on Syphilis ..... 25 

Dalton on the Circulation .... 7 
Dalton's HumanPhysiology ... 8 

Davenport on Diseases of Women . . . 28 

Davis' Clinical Lectures ... 17 

Draper's Medical Physics .... 7 
Druitt's Modern Surgery .... 20 
Duncan on Diseases of Women ... 28 
Dungllson's Medical Dictionary ... 5 
Edes' Materia Medica and Therapeutics . 12 

Edison Diseases of Women .... 27 
Ellis' Demonstrations of Anatomy . . 7 

Emmet's Gynaecology . . . 28 

Erichsen's System of Surgery ... 21 

Farquharson's Therapeutics and Mat. Med. . 12 
Fenwick's Medical Diagnosis ... 16 

Flnlayson's Clinical Diagnosis ... 16 
Flint on Auscultation and Percussion . . 18 

Flint on Phthisis 18 

Flint on Respiratory Organs ... 18 

Flint on the Heart 18 

Flint's Essays ...... 18 

Flint's Practice of Medicine ... 14 

Folsom's Laws of U. S. on Custody of Insane . 19 
Foster's Physiology ..... 8 

Fothergill's Handbook of Treatment . . 16 

Fownes' Elementary Chemistry ... 9 
Fox on Diseases of the Skin .... 26 

Frankland and Japp's Inorganic Chemistry . 9 
Fuller on the Lungs and Air Passages . . 18 

Gant's Student's Surgery . . . .20 

Gibney's Orthopaedic Surgery . 20 

Gould's Surgical Diagnosis . . . .21,31 

Gray's Anatomy . . . . . .5 

Greene's Medical Chemistry .... 9 

Green's Pathology and Morbid Anatomy . 13 

Griffith's Universal Formulary . . .12 

Gross on Foreign Bodies in Air-Passages . 18 

Gross on Inipotence and Sterility ... 25 
Gross on Urinary Organs .... 25 

Gross System of Surgery . . . . 20 

Habershon on the Abdomen . . . 16 

Hamilton on Fractures and Dislocations . 22 

Hamilton on Nervous Diseases ... 19 
Hare's Practical Therapeutics . . . 11 

Hartshorne's Anatomy and Physiology . . 6 

Hartshorne's Conspectus of the Med. Sciences . 3 
Hartshorne's Essentials of Medicine . . 14 

Hermann's Experinaental Pharmacology . 11 

Hill on Syphilis 25 

Hillier's Handbook of Skin Diseases . . 26 

Hoblyn's Medical Dictionary ... 3 

Hodge on Women . . . . .28 

Hofimann and Power's Chemical Analysis . 10 
Holden's Landmarks ..... 5 
Holland's Medical Notes and Reflections . 17 

Holmes' Principles and Practice of Surgery . 22 
Holmes' System of Surgery . . .22 

Horner's Anatomy and Histology . . 6 

Hndson on Fever . ... 4 

Hutchinson on Syphilis . . . . 25, 31 

Hyde on the Diseases of the Skin . . .26 

Jones (C. Handfield) on Nervous Disorders . 19 



Juler's Ophthalmic Science and Practice . 23 

King's Manual of Obstetrics .... 29 

Klein's Histology . . . . . 13, 31 

Landis on Labor ..... 30 

La Roche on Pneumonia, Malaria, etc. . . 18 

La Roche on Yellow Fever .... 14 

Laurence and Moon's Ophthalmic Surgery . 23 
Lawson on the Eye, Orbit and Eyelid . . 23 

Lea's Chapters from Religious History of Spain 31 
Lea's Studies in Church History ... 31 
Lea's Superstition and Force . . .31 

Lee on Syphilis ... 25 

Lehmann^s Chemical Physiology ... 8 
Leishman's Midwifery .... 30 

Lucas on Diseases of the Urethra . . .24,31 

Ludlow's Manual of Examinations . . 3 

Lyons on Fe\ er . . . . . .14 

Maisch's Organic Materia Medica ... 11 
Marsh on the Joints . . .21,31 

May on Diseases of Women .... 28 

Medical News . ... 1 

Medical News Visiting List .... 3 

Medical News Physicians' Ledger ... 3 
Meigs on Childbed Fever .... 29 

Miller's Practice of Surgery .... 21 

Miller's Principles of Surgery ... 21 

Mitchell's Nervous Diseases of Women . . 19 

Morris on Diseases of the Kidney . . .24,31 

National Dispensatory .... 12 

National Medical Dictionary . . 4 

Neill and Smith's Compendium of Med. Scl. . 3 
Nettleship on Diseases of the Eye . . .23 

Norris and Oliver on the Eye ... 23 

Owen on Diseases of Children . . .30, 31 

Parrish's Practical Pharmacy ... 11 

Parry on Extra-Uterine Pregnancy . . 29 

Parvin's Midwifery ... . .29 

Pavy on Digestion and its Disorders . . 17 

Payne's General Pathology .... 13 

Pepper's System of Medicine ... 15 

Pepper's Forensic Medicine .... 31 

Pepper's Surgical Pathology . . .13,31 

Pick on Fractures and Dislocations . . 22, 31 

Pirrie's System of Surgery . ... 21 

Playfair on Nerve Prostration and Hysteria . 19 
Playfalr's Midwifery ....."" 

Politzer on the Ear and its Diseases 

Power's Human Physiology .... 

Purdy on Bright's Disease and Allied A flfections 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 
Remsen's Theoretical Chemistry . 
Reynolds' System of Medicine 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases . . 

Roberts' Compend of Anatomy 

Roberts' Surgery . . . . 

Robertson's Physiological Physics 

Ross on Nervous Diseases .... 

Savage on Insanity, including Hysteria . 

Schafer's Essentials of Histology, 

Schreiber on Massage . ... 

Seller on the Throat. Nose and Naso-Pharynx 

Senn's Surgical Bacteriology 

Series of Clinical Manuals 

Simon's Manual of Chemistry 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

Smith (J. Lewis) on Children 

Smith's Operative Surgery . 

Stllle on Cholera .... 

Still6 & Maisch's National Dispensatory 

Stint's Therapeutics and Materia Medica 

Stimson on Fractures and Dislocations 

Stimson's Operative Surgery 

Students' Series of Manuals . 

Sturges' Clinical Medicine 

Tait's Diseases of Women and Abdom. Surgery 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Taylor's Atlas of Venereal and Skin Diseases 

Taylor on Venereal Diseases 

Taylor on Poisons 

Taylor's Medical Jurisprudence 

Thomas on Diseases of Women 

Thompson on Stricture 

Thompson on Urinary Organs 

Tidy's Legal Medicine . 

Todd on Acute Diseases 

Treves' Manual of Surgery . 

Treves' Surgical Applied Anatomy 

Treves on Intestinal Obstruction . 

Tuke on the Influence of Mind on the Body 

Vaughan & Novy's Ptomaines and Leucomaines 

Visiting List, The Medical News . 

Walshe on the Heart . 

Watson's Practice of Physic . 

Wells on the Eye .... 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Williams on Consumption . 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy . . „ •., „ ^ 

Winckel on Pathol, and Treatment of Childbed 

Wohler's Organic Chemistry 

Wood head's Practical Pathology . 

Year-Books of Treatment for 1886, '87, '89 and 

Yeo on Food in Health and Disease 



23 

8.31 

24 

10,31 
28 
10 
14 
17 
24 
7 
20 
7,31 
19 

19,31 
13 
17 
18 
13 
4 
8 
18 
18 
30 
22 
14 
12 
11 



4 

17 
28 
29 
16 
26 
25 
31 
31 
27 
24 
24 
31 
17 
21 
6,31 
21,31 
19 
16 
3 
18 
14 



6 
29 

8 
13 

90 17 
17.31 



LEA BROTHERS & CO., Philadelphia. 



